Head of Household Verification
I, (Name of Head of Household) do verify that,
(Parent or Guardian), the parent of (children listed below)
LIST ALL STUDENTS IN THE FAMILY
*Do not include the Head of Household’s family unit*
Student 1
Not Satisfied
Name of Student
Date of Birth
Student 2
Not Satisfied
Name of Student
Date of Birth
Student 3
Not Satisfied
Name of Student
Date of Birth
Student 4
Not Satisfied
Name of Student
Date of Birth
You address
Is this a temporary or permanent address
Temporary
Permanent
Signature of Head of Household
Signature of Parent
AR Annotated Code §6-18-202 (3)Any person who knowingly gives a false residential address for purposes of public school enrollment is guilty of a violation and subject to a fine not to exceed one thousand dollars ($1000).
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