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Brentwood UFSD: Change of Address Questionnaire

This form is meant to be used to declare a Change of Address for a current student in the Brentwood School District. Parents/Guardians are required to complete the following portions of this form:

Change of Address Questionnaire
Official, state or other government issued Parent/Guardian picture ID
Two (2) documents verifying full name and address (see list below)
Affidavit of Residency: For Homeowners and Renters
Landlord/Owner Affidavit: For Non-Homeowners - This will be sent to you separately after completing this form

The following documents are accepted as verification for full name and address:

Lease agreement
Residential utility bill (gas, water or electric) in the residents’ name issued by a utility company (ex. National Grid or LIPA), must be dated within the past 60 days
Cable services bill provided to the residence including the name of the parent, the address of the residence and must be dated within the past 60 days
Documentation or letter on letterhead from a federal, state, or local government agency, including the IRS, the federal Office of Refugee Resettlement (ORR), the Human Resources Administration, or the Administration for Children Services (ACS), or an ACS subcontractor, indicating the resident’s name and address and must be dated within the past 60 days
Income tax form for the last calendar year
Official payroll documentation from an employer issued within the past 60 days, such as a paystub with home address, a form submitted for tax withholding purposes, or payroll receipt (a letter on the employer’s letterhead is not adequate) and must include home address and be dated within the past 60 days
Voter registration documents, which include the name of the parent or guardian and the address of residence
Unexpired membership documents based upon residency (ex. neighborhood residents’ association, library, etc.), which include the name of the parent and the address of residence
Evidence of custody of the child including judicial custody orders or guardianship papers issued within the past 60 days, which include the name of the student and guardian, and address of residence

Change of Address Questionnaire

Name of School

Student Last Name *

Student First Name *

Student Middle Name

Gender *

Male

Female

Date of Birth - Month (MM) *

Date of Birth - Day (DD) *

Date of Birth - Year (YYYY) *

Grade (Preschool-12) *

Student ID

Previous Address

New Street Number and Name *

New Town *

New State *

New Zip Code *

Parent/Guardian Phone Number *

Parent/Guardian Email Address *

The answer you give below will help the District determine what services you or your child may be able to receive under the McKinney-Vento Act. Students who are protected under the McKinney-Vento Act are entitled to immediate enrollment in school even if they do not have the documents normally needed, such as proof of age or residency, school records, medical or immunization records, or birth certificate. Students who are protected under the McKinney-Vento Act may also be entitled to free transportation and other services.

Where is the student currently living? (Please check one box)

In a public or private shelter that is temporary or transitional.

If yes, please describe.

With another family or other person because of loss of housing or as a result of economic hardship -sometimes referred to as “doubled-up.”

If yes, please describe.

In a hotel/motel due to lack of alternative adequate accommodations.

If yes, please describe.

In a car, park, bus, train, or campsite.

If yes, please describe.

Other temporary living situation (i.e., trailer park, campground, public places, abandoned building, street, or any other inadequate living space).

If yes, please describe.

In permanent housing. (Includes renters)

Parent/Guardian Picture ID

Are you the legal parent/guardian of the student referred to on this form? *

Yes

Please submit a scanned copy or picture of your official photo ID. *

List of Allowed file types

Proof of Residence

Two (2) of the documents listed above, verifying full name and address dated within the specified timeframes.

Do you have two proofs of residency from the list above? *

Yes

Do you own your residence? *

Yes

If you own your residence please upload your Mortgage, Deed or Tax Bill

List of Allowed file types

Proof of Residence #1 (Do not upload any affidavits here) *

List of Allowed file types

Proof of Residence #2 (Do not upload any affidavits here)

List of Allowed file types

Affidavit of Residency

Affidavit of Residency: English Download

Affidavit of Residency: Spanish Download

Please attach the completed version of the document. *

List of Allowed file types

Please use this space to attach additional pages as necessary.

Add attachment

List of Allowed file types

Type and Sign name of Parent, Guardian, or Student (for unaccompanied homeless youth)

Type your name and sign below

Clear Show me how

Date Signed *

Approvals

A number of approval stages need to be completed before this submission can be accepted.

Change of Address Received by Registration - In Review

Appropriate approvers from the Change of Address Received by Registration - In Review group will be automatically allocated for this approval stage.