affidavit of residence - Polk County Public Schools

Revised
Oct 2013
AFFIDAVIT OF RESIDENCE
(AFFIDÁVIT DE DOMICILIO)
Owner or Lease Holder (Print)
(Dueño o Arrendador en letra de imprenta)
_____________________________________
Signature (Firma)
_____________________________________
Address (Dirección)
_____________________________________
City (Ciudad), State (Estado) & Zip Code (Código Postal)
______________________________________
Phone including area code (Teléfono incluyendo código de área)
______________________________________________________
Relationship to applicant (Relación con el/la solicitante)
........................................................................................................................................................................................
The permanent residence of _________________________________________ is
(El domicilio permanente de)
Name of Parent/Guardian (Nombre del Padre/Tutor)
__________________________________________________________________
Address (Dirección)
City (Ciudad)
State (Estado)
Zip Code (Código Postal)
__________________________________________
Signature of Parent/Guardian
(Firma del Padre/Tutor)
(Para el Notario Público solamente)
State of Florida (Estado de la Florida)
County of (Condado de) ___________________
Sworn to (or affirmed) and subscribed before me this _____ day of _____, 20___, by
___________________(Owner/Lease Holder) and ________________ (Parent/Guardian).
(NOTARY SEAL)
____________________________
Notary Signature
Personally Known ______ OR Produced Identification _______
Type of Identification Produced_______________________________________________
…any person making a false oath before a notary public shall be guilty
of perjury and be subject to the penalties, forfeitures, and disabilities
that are prescribed by law in cases of willful and corrupt perjury.
…cualquier persona que haga un juramento falso frente a un notario público será culpable de
perjurio y sujeto a las penalidades, confiscaciones e incapacidades que están preescritas por la ley
en casos de mala intención o perjurio corrupto.
History-September 13, 1822; RS 219; GS 304; RGS 415; CGL 481; s. 20, ch.
73.334
Revised October 2013