We,

OF NATURAL PARENT bib

This is a legal document. The information you provide will be used to
determzne whether the studentis} is/are entitled to attend the Rochester



City Sehoo: District on a tuition-tree basis.
Every question must be answered and the af?davit must be notarized. or

LilC at? idavit ivill not be considered. Once completed, return the af?davit
and any additional documentation to the Student Placement Of?ce.

STATE OF NEW YORK 
COUNTY MONROE )1 55:

THE UNDERSIGNED, BEING DULY SWORN, DEPOSES AND STATES

THE 
Carrie Housto?

 

 

 

 

1. My name is:
2. I am the Natural Parent of: (list ehtil'dl?en) name and DOE)
Th? leon 2- - 04

3. My permanent address is:

1525 bat-56L Ln. AN 
Gama Prat/e 75050

 

 

My telephone number is: (give work and home]

4.

 

 

 

I have ?6.13 fed (rented or owned) my permanent residence for
years; or months. If I lease, my lease

expires on

5,

 

My occupation is: (job title; name of employer; address of
employer; usual days and hours worked)

 

unem played.--

 

 

The marital status of myself and the ild(ren?s) other Natural
Parent is: sepctra

If separated or divorced, state which parent was ranted
custody of the child( (:ren) 

Custody was granted by: (check one)

Court order (state the name of the court, date of the
order, and attach a copy of the order}

 

 

 

Agreement between parents (copy of written agreement
signed by both parents must be attached)

3? Other (explain)
Cliff/f [Audion dud: 710 

{Hides-{701? 1&5qu my Abusj?VC halfbaud

?t)Ld me j?ka-c. I flu/CIR!?


b6 I777 mall'f.
The child(ren) currently live with: (name and address and work

and home phone) (This person is the ?Custodial Parent?)

 
 
 

Velm

 

 

hookah}? NJ 1%qu

  

ll.

l2.

13.

14.

15.

16.

The childtren) have lived with the following people over the past
three years: (name and address and phone)

Carri Mus-ion

1535 Dada LN, lip-Vi \qo?b
??md Dream.) TX: ?13050

 

I expect the child(ren) to live with the Custodial Parent at
his/her present location (as stated in #10) until: (give
approximate date) Andelcinkz

State the relationship of the childfren) to the Custodial Parent:

Their {lam?l? 

 

 

 

State the reasons why the child(ren) is [are residing with the
Custodial Parent:

(Hf will? ?it; [Sum-1'} 


i
lit-lord 41.? have mm bung (:?bugzs?

him? :1 Mali; and 1' (INT: [70+ 5- la 
fl'lwi?ju. ?l'c lfi?JH" (?51 04: l" 

State whether parental custody and control has been legally
transferred to the Custodial Parent and, if so, why: (attach all

relevant court orders)

140

 

 

State whether the Natural Parent intends to take back custody
and control and, if so, when and why;

Mr:

 



 

17.

18.

19.



22.

State who will clai he child(ren) as de ndent for th
current tax year: {78mm P6 


Stste the amount of ?nancial support you provide to the
ch11d(ren): (how much money and how often)

I mount swoowr?r all
pmn?l' will bt Sup?DOHi/tg
mom local!?

Stato amount of ?nancial support the Custodial Parent
promdcs to the child(rcn): (how much and how often}

\{clmot Hamdtj 
'9l?axn0'lov0 

 

 

 

State who is responsible for providing the child{rcn) with food,
clothing, and other necessities:

\[tlma W5 mm be. ?spa-ambit
avwm?m?l
if 

 

State who pays for the child(rens) medical expenses: (if covered
by health insurance, who covers them)

Velma l?lcmd?j will be om +o
Om 2,than -


 

State when and how often the chi]d(rcn) stay overnight with the
Custodial Parent; and with the Natural Parent:

A5 01" new outlawed 

mm adr- gu Hm.

 

 

 

Minor; l?gt: pins inm'est as. Ur: rate. and any omer
damages 3.: 5mg Lhtrei'mm. mamamg mt: ust :ncurred by Dist: 1c: L:
mciud?ng reasonabie legal fees.

 

rolled such rh?rges.?
i u' 

. 
Dee 

Signature of Naiwal Puf?n;
Nazrnc



STATEof: "ear 0 . bef re me. the undersi ned,
. 
personally known to

personally apprafeci 
me or provad to me on me basis of satisfactory evidence to be the
individual uhosc name 1S. subscribed to on the 'thin instrume and

acknowledged to m: that he/she executed the 

and that, bv his,"hcr signarure or:- the: instrume
., I i - 

person upon the mamdual

 

 

   
   
 

 
 

the ind: i
,6 cc 0