Mount Vernon City School District

Mount VernonCitySchool District

Pupil Personnel Services

Landlord Affidavit

For Permanently Housed Students Only

State of New York)

County of Westchester)

______being duly sworn deposes and says:

(Owner/Landlord/ Management Company)

I am the owner and or landlord of the premises known and designated as Lot # ______Block#______

at ______Mount Vernon, New York. These

(Address of Residence)

premises constitute a legal residence. ______is a tenant occupying

(Tenant’s Name)

apartment # ______occupied on the ______floor of the building.

______occupies this apartment under a (written/oral) lease agreement,

(Tenant’s Name)

which commenced on the ______day of ______in the year ______.

(Day) (Month)(Year)

______occupies this apartment with the following persons:

(Tenant’s Name)

Name AgeRelationship To Tenant

This affidavit is made in order to induce the Mount VernonCitySchool District to enroll

______into its school system with the understanding that all

(Student’s Name)

Non-resident tuition costs will be reimbursed to the school district in the event the student residency is

determined not to be in the district.

The undersigned is aware that the Mount Vernon City School District Board of Education, in admitting

______as (a) tuition free student(s), is relying upon the

(Student’s Name)

truthfulness of the statements contained herein and may, in its discretion; require further verification of the

facts contained herein, including without limitation, on site residency checks by attendance teachers and/or any

other designee(s) of the school superintendent.

I further realize that in the event I misrepresented any of the facts herein, the Mount VernonCitySchool

District may seek to recover from any damages it may sustain as a result thereof including without limitation,

tuition costs incurred by ______while attending any schools(s) in the

(Student’s Name)

Mount VernonCitySchool District.

I declare and affirm that the statements made in this application, including accompanying documents are true, complete and correct. I understand that any false or misleading information in, or in connection with, this application may be cause for denial of my child’s enrollment in the Mount VernonCitySchool District and may result in criminal prosecution and/or the imposition of non-resident fees.

______

Owner/Landlord’s Signature Today’s Date

Notary Certification of Identification

State of ______, County of ______.

I certify that on the date set forth below the named individual above did appear personally before me

and I did identify this person by: (a) comparing his/her physical appearance with the photograph on

the identifying document presented by the said person and (b) comparing the applicant’s signature on this form with the signature on his/her identifying document. The statements in this document are subscribed and sworn before me by the applicant on this ______day of ______,

(Date) (Month)

______.

(Year)

Signature of Notary Public: ______

Notary ID Number: ______Expiration Date: ______

Notary Seal or Stamp

8/2010Landlord Affidavit Page 1