State of Arizona - Affidavit of Shared Residence

State of Arizona

Affidavit of Shared Residence

This document is to be completed only for those parents or legal guardians who are unable

to document their own residence because of extenuating circumstances,

such as sharing living accommodations with another person who is not the student’s parent or legal guardian.

The parent or legal guardian must complete the “Arizona Residency Documentation Form” and have the individual

with whom they reside complete, sign and have notarized this “Affidavit of Shared Residence.” Submit both

forms to the school or district with a photocopy of one of the documents listed below—which clearly shows

the full name and residential address (no P.O. boxes) of the individual with whom you are residing.

Personal information other than name and address (such as Social Security Number, account numbers, etc.) should be blacked

out on the document before providing it to the school or district.

I swear or affirm that I am a resident of the State of Arizona and that the persons listed below reside with me at my

residence, described as follows:

Persons who reside with me:

_______________________________________________________________________________________________________________

Location of my residence (physical address or location; please do not use P.O. box):

_______________________________________________________________________________________________________________

I submit in support of this attestation a copy of the following document that displays my name and current

residence address or physical description of my property:

 Valid Arizona driver’s license, Arizona identification card or motor vehicle registration

 Valid Arizona Address Confidentiality Program authorization card

 Real estate deed or mortgage documents

 Property tax bill

 Residential lease or rental agreement

 Water, electric, gas, cable, or phone bill

 Bank or credit card statement

 W-2 wage statement

 Payroll stub

 Documentation from a state, tribal or federal government agency (Social Security Administration, Veteran’s

Administration, Arizona Department of Economic Security)

Printed Name of Affiant: ________________________ Signature of Affiant: ________________________

Acknowledgement

State of Arizona, County of Coconino

The foregoing was acknowledged before me this ______ day of ___________________________, 20______,

by _________________________________________________ (Name of Affiant).

________________________________________ My Commission Expires: ______________________

Notary Public

ADE #2306606AASR Revised 4/4/16