ROBERT L. EHRLICH, JR., Governor                             Ch. 207

____ASSIGNMENT OF A PARENT OR LEGAL GUARDIAN OF A

CHILD TO ACTIVE MILITARY DUTY

(III) THE NAME AND LAST KNOWN ADDRESS OF THE CHILD'S
PARENT(S) OR LEGAL GUARDIAN IS:

(IV)    MY KINSHIP RELATION TO THE CHILD IS____________

(V)     MY ADDRESS IS:

STREET                                                  APT. NO.

CITY                       STATE                       ZIP CODE

(VI)    I ASSUMED INFORMAL KINSHIP CARE OF THIS CHILD FOR 24
HOURS A DAY AND 7 DAYS A WEEK ON_______________(DAY/MONTH/YEAR).

(VII)  THE NAME AND ADDRESS OF THE LAST SCHOOL THAT THE
CHILD ATTENDED IS:__________

(VIII) THE COUNTY SUPERINTENDENT MAY VERIFY THE FACTS
CONTAINED IN THE FOREGOING AFFIDAVIT AND CONDUCT AN AUDIT ON A
CASE-BY-CASE BASIS AFTER THE CHILD HAS BEEN ENROLLED IN THE COUNTY
PUBLIC SCHOOL SYSTEM. IF THE COUNTY SUPERINTENDENT DISCOVERS FRAUD OR
MISREPRESENTATION, THE CHILD SHALL BE REMOVED FROM THE COUNTY PUBLIC
SCHOOL SYSTEM ROLL.

(IX) I SOLEMNLY AFFIRM UNDER THE PENALTIES OF PERJURY
THAT THE CONTENTS OF THE FOREGOING ARE TRUE TO THE BEST OF MY
KNOWLEDGE, INFORMATION, AND BELIEF.

SIGNATURE OF AFFIANT

(DAY/MONTH/YEAR)

(X) ANY PERSON WHO WILLFULLY MAKES A MATERIAL
MISREPRESENTATION IN THIS AFFIDAVIT SHALL BE SUBJECT TO A PENALTY
PAYABLE TO THE COUNTY FOR THREE TIMES THE PRO RATA SHARE OF TUITION FOR
THE TIME THE CHILD FRAUDULENTLY ATTENDS A PUBLIC SCHOOL IN THE COUNTY.

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