Proof of Domicile
Student Information
Student’s Name: ____________________________________________________
Grade: __________________
Parent/Guardian Name: _______________________________________________
Phone: ________________
New Address
House Number: ________ Street Name: ___________________________
Last School Attended: _______________________
City/Zip: _____________________
School serving new address: ________________________
The following documents may be used to establish residence per Rowan-Salisbury School System Board of Education.
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Current utility bills (within the last 30 days)
Social Services financial assistance documentation
Current lease agreements (within the last 30 days)
Current rent receipts (within the last 30 days)
Current contractor agreement/loan agreement for a primary residence with verification of utility bill to
follow (within the las 30 days)
Current valid NC Driver’s license*
(only to be used if no other documentation listed above is available)
Property owner verifies that the family is living at the domiciled address*
*I, __________________________, do hereby state that _________________________________________________
lives at: House #______________ Street Name_________________________________________________________
City___________________________________ State & Zip________________________________________________
Signature of Property Owner/Lessor_________________________________________ Date: ___________________
*Where documentation is incomplete, additional verification may be required.
Note: If it is found that a person willfully and knowingly provides false information on this affidavit, that person shall
be guilty of a Class I Misdemeanor and shall pay to the Rowan-Salisbury School System an amount equal to the cost of
educating the student for the time during enrollment.
Signature of Parent/Guardian or Legal Custodian: _____________________________________ Date: ____________
Direct questions to: Amanda Howard, Enrollment Specialist
amanda.howard@rss.k12.nc.us
cc: Enrollment Specialist
Database entry: __________________
Rev 4/16