BOARD OF EDUCATION OF THE BOROUGH OF MADISON
359 Woodland Road • Madison, NJ 07940 • (973) 593-3100 • Fax (973) 301-2170
Form 200-2b – Affidavit of Resident
(Non-Parent/Guardian)
___________________________________________________________________
This is a legal document which must be sworn to and signed in the presence of Notary Public. If Applicant is
married, both husband and wife must sign this Affidavit. You bear the burden to provide proof sufficient to
establish the existence of a family or economic hardship which renders neither parent capable of caring for or
providing support of the pupil, and why the pupil will be residing with you. If the information provided is false,
the Madison Board of Education will seek reimbursement of regular tuition at a cost of
$_________________________ annually (if the student is determined to be special needs, the tuition rate will
be adjusted to reflect the cost of the education provided). The Madison Board of Education may file a criminal
charge against you for any willfully false statement.
STATE OF NEW JERSEY)
:
COUNTY OF MORRIS )
I/We ___________________________________________, and _____________________________________
(Resident’s Name)
(Spouse)
of full age, being sworn upon my/our oath according to law, depose and say:
I.
I/We reside at No.
_________________________________________________________________,
In the Borough of Madison, State of New Jersey.
I/We do/do not (circle one) own this property. If I/we own this property, I/we have attached a true
copy of the Deed. If I/we lease the premises, I/we have attached a true copy of the Lease. If I/we do
not have a written lease, I/we have attached a completed and notarized Owner/Landlord Affidavit
Form. If applicable, the name and address of my/our landlord is _____________________________
_________________________________________________________________________________
_________________________________________________________________________________
II.
The information provided in the Affidavit is accurate and complete. I/We fully understand that I/we
may be held responsible for payment of tuition in the amount of $_______________________
annually if the claim for school admission, free of charge, is rejected by the Commissioner of
Education.
III.
The following information is presented to the Board of Education in support of my request for free
admission of _____________________________________________________________________
(Pupil’s Name)
A.
1. Name of Pupil’s parents:
_____________________________________________________________________________
(Mother’s Last Name)
(First Name)
_____________________________________________________________________________
(Father’s Last Name)
(First Name)
2. Mother’s Address:
_____________________________________________________________________________
__________________________________
(Work Phone No.)
_________________________________________
(Home Phone No.)
Father’s Address
______________________________________________________________________________
___________________________________ _________________________________________
(Work Phone No.)
(Home Phone No.)
3. Name of Legal Guardian/Resident, if applicable:
______________________________________________________________________________
(Last Name)
(First Name)
4. Address of Legal Guardian/Resident:
______________________________________________________________________________
_________________________________________
(Work Phone No.)
_________________________________
(Home Phone No.)
5. Are you the Legal Guardian? ______________________________________________________
If not, have you applied to Court?
Yes
No (Circle One)
When? ______________________________________________________________________
(Provide Proof)
IDENTIFY AND ATTACH ALL DOCUMENTATION TO SUPPORT THIS ANSWER
B.
1.
School and grade pupil desires to attend:
_____________________________________________________________________________
2. What school did pupil last attend?
_____________________________________________________________________________
(Name of School)
_____________________________________________________________________________
(Address)
______________________________________________________________________________
3. Date of last attendance: __________________________________________________________
C.
1. Address at which this pupil is now living:
_____________________________________________________________________________
_____________________________________________________________________________
2. Telephone Number: _____________________________________________________________
3. Last prior address of pupil:
_____________________________________________________________________________
_____________________________________________________________________________
D.
1. With whom does this pupil now live?
_____________________________________________________________________________
(Last Name)
(First Name)
2. What relation are you to this pupil? (Be Specific)
_____________________________________________________________________________
_____________________________________________________________________________
3. Set forth in full and complete detail why this Pupil is not living with parent. (Be Specific)
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
IDENTIFY AND ATTACH ALL DOCUMENTATION TO SUPPORT THIS ANSWER
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
4. Set forth in full and complete detail why neither parent is capable of caring for or providing
support of the pupil, and why the pupil will be residing with you. (Be Specific)
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
IDENTIFY AND ATTACH ALL DOCUMENTATION TO SUPPORT THIS ANSWER
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
5. The pupil will / will not (circle one) be residing with me for the sole purpose of receiving a free
public education in the district.
E.
1. Do the parent(s) currently pay any of the costs of maintaining this pupil?
Yes _________________
2. If so, how much?
No _____________________________
$ ___________________ per week
$ ___________________ per month
$ ___________________ per year
For what purpose? _____________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
F.
1.
During the time the pupil resides with you, will you receive any payments or contributions either
in money or in lodging, food, clothing, medical insurance/expenses, recreation or any other thing
or service of value in connection with the support, maintenance and education of the pupil?
Yes __________________________
No __________________________
Explain (Be specific as to amount, type and purpose of payment or contribution.)
_________________________________________________________________
_________________________________________________________________
__________________________________________________________________
___________________________________________________________________
IDENTIFY AND ATTACH ALL DOCUMENTATION TO SUPPORT THIS ANSWER
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
G.
1.
Who is furnishing the pupil a permanent home at his/her own expense?
_____________________________________________________________________________
2.
Who is financially responsible for the pupil?
_____________________________________________________________________________
3.
When do you expect the pupil to move out of your home?
_____________________________________________________________________________
(Provide specific date)
4.
When do you expect the pupil to move out of the district resident’s home?
____________________________________________________________
(Provide specific date)
5.
During the time the pupil resides with the person named in C-2, will the person named in C-2
make any payments or contributions either in money or in lodging, food, clothing, medical
insurance/expenses, recreation, or any other thing or service of value in connection with the
support, maintenance, and education of the pupil?
Yes ___________________________
No ___________________________
Explain (be specific as to amount, type, and purpose of payment or contribution):
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
H.
1.
Does this pupil currently live with his/her parents any part of the week?
_____________________________________________________________________________
If so, how many days per week? ___________________________________________________
2.
Any part of the month?___________________________________________________________
If so, how many days per month? __________________________________________________
3.
Any part of the year? ____________________________________________________________
If so, how many days per year? ____________________________________________________
I.
1.
During this school year, will this pupil live with his/her parents any part of the week?
_____________________________________________________________________________
If so, how many days per week? ___________________________________________________
2.
Any part of the month? __________________________________________________________
If so, how many days per month? __________________________________________________
3.
Any part of the year? ___________________________________________________________
If so, how many days per year? ___________________________________________________
4.
Will this pupil live with you during the summer?
_____________________________________________________________________________
J.
1.
Is this pupil a state ward? _________________________________________________________
2.
State the name and address of anyone who provides any part of this child’s support and state the
amount of such support.
_________________________________________________________________________________
_________________________________________________________________________________
K.
1.
Are this pupil’s expenses paid fully or in part by any charitable agency?
_____________________________________________________________________________
2.
If so, give name and address of agency.
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
IV.
I will assume all personal and financial obligations for the pupil with respect to school
requirements, and will receive no contribution or payment from the Parent in connection with
the support or maintenance or education of the pupil.
V.
I am making this affidavit pursuant to N.J.S.A. 18A:38-1(b), to induce the Madison Board of
Education to accept said pupil in the public schools of the District free of charge.
VI.
I understand that if any of the information provided above is changed, for any reason, it is my
responsibility to immediately notify the Superintendent of Schools of the Madison School
District.
VII.
I understand that the Board of Education reserves the right to make periodic checks as to our
continuing support for the Pupil named above and his/her residence in our home. In addition,
the Board of Education reserves the right to require additional documentation to verify the
residency and dependency of the Pupil named above. I agree to cooperate with any
investigation by the Board of the facts set forth in this affidavit.
The above statements and attachments are true and complete to the best of my knowledge. I
know that if they are willfully false, I am subject to punishment, including, but not limited to,
prosecution and personal liability for the payment of tuition for the entire school year, or any
portion thereof.
Sworn to and subscribed
before me this ______________________
day of ____________________________, ______.
__________________________________
Signature of Resident
_________________________________________
Notary Public
Sworn to and subscribed
before me this ______________________
day of ____________________________, ______.
__________________________________
Signature of Resident
_________________________________________
Notary Public
Revised 09/14