DECLARATION OF DOMICILE FOR MULTI-PARISH CHARTER SCHOOL APPLICATION

December 17, 2008

Full Name of Parent/ Legal Guardian:

Street Address, City, State, Zip:

Name of Charter School Applicant:

Date State Domicile Began:

I hereby certify that my son / daughter is domiciled at the above-stated address.

Signed:
    Date:

In support of the domicile certification, please place your initials next to the each one of the following that applies to the domicile you have claimed above.

I am registered to vote in the State of Louisiana;

My son / daughter and I usually sleep there;

My spouse and minor children, if any, reside with me and the charter school applicant at this address;

The charter school applicant and I receive most of our mail addressed to us at this address.

Do you or the charter school applicant have any other residences or mailing address:

Yes
No

If yes, please list any and all residences and mailing address:

www.isl-edu.org