State of Mississippi, County of Pike

Affidavit of Residency

(Custodial Adults other than parent or guardian)

Personally approved before me, the undersigned legal authority in and for the jurisdiction aforesaid, the within named, __________________________, who states under oath and penalty of perjury the following:

1.      I reside at _______________________________________________, which

       is located within the South Pike School District.

2.      The relationship between ________________________ and Affiant is ________________________________________________________.

3.      __________________________________ lives in my home full time.

4.      The reasons why ______________________ is living with me are as follows: __________________________________________________________

      __________________________________________________________

5.      _______________________________ is not living with me for the purpose of

      attending school in the South Pike School District.

6.      I understand that _______________________ will not be allowed to enroll in

      the South Pike School District if ___________________ is not living with me

      for the purpose of attending said school.

            Signature of Custodial Adult

________________________________

Signature of Legal guardian

________________________________

SWORN TO AND SUBSCRIBED before me on this ______ day of _____, A.D.20____.

Signature:___________________________________

My Commission Expires: ______________________