3120P – Exhibit C

Page 1 of 2 Bellevue School District 7/18/17

CHANGE OF ADDRESS AND UPDATED RESIDENCY VERIFICATION FORM

To officially change your student's address, you are required to reestablish residency. In order to enroll in school State law requires that a student reside within the District boundaries and be able to prove residency or have been approved for an Interdistrict transfer.

PREVIOUS ADDRESS DATE OF MOVE

Parent/Guardian signature PLEASE PRINT NAME DATE

Please list below the names of additional siblings living at this new address who attend the Bellevue School District:

Student: Last Name First Name School Date of Birth Grade

Student: Last Name First Name School Date of Birth Grade

Student: Last Name First Name School Date of Birth Grade

Please check the documents you have included with this notice.

To verify residency, you must provide two of the items listed below; each bullet counts as one item.

All addresses on the documents must match the address of your residence

If you are unable to provide any of the above items, please contact the District Student Placement office at SPResidency@bsd405.org or at 425-456-4200 to create and sign a Residency Agreement.

This Agreement will give you extra time to collect the needed documents.

Government Mail (e.g. car registration; Good to Go! bill or letter; letter from Social Security,

immigration, unemployment, health finder exchange or DMV; USPS Change of Address form; election

ballot. Correspondence from the Bellevue School District does not qualify as Government Correspondence)

Homeowners Insurance Policy Declaration

Property Tax bill (must have been received in the mail, not printed off a website)

Redacted 1099 or W-2 (Social Security Number and dollar amounts blacked out)

Unexpired Lease Agreement (must be signed by both parties with 2 months cancelled checks or proof of

online banking payment of lease)

Utility Bills (2 consecutive utility bills from the same utility company dated within the last 3 months –

accepted utilities include water, sewer, gas, electricity, or garbage; the mailing and service address must

be the residence address. Cable, internet and phone bills are not accepted.)

If you are part of the Washington State Address Confidentiality Program, an official letter from the

Address Confidentiality Program stating the attendance area school fulfills the requirement to establish

residency in the Bellevue School District. You must submit a renewed letter to the school each year.

Bellevue School District

2) CELL HOME WORK PARENT PHONE 1) CELL HOME WORK

ZIP CODE STATE CITY

DATE OF BIRTH

3120P – Exhibit C

______ My student (listed above) resides with me at least four (4) nights per week at the address listed above,

(Initial) which is my primary residence.

NOTE: If your child does not reside with you at least four (4) nights per week at the above-listed

address, please initial here_______, and attach a written explanation of where and with

whom your child resides each day of the week.

_______I agree to notify the District/School within (5) days when I change my residence or that of my student to a

(Initial) new address, either within or outside the District.

_______Home visitation and/or other residency verification is part of a periodic process to confirm current residency

(Initial) status.

_______The District will investigate all cases where it has reason to believe that residency status has changed and/or

(Initial) false information has been provided, which may include the use of private investigators to verify residency

status. Verification may include home visits.

_______Investigations that reveal students have enrolled on the basis of providing false information will be cause for

(Initial) revocation of the student’s school assignment and disenrollment from the District.

I certify the foregoing information to be true and correct, and that any and all copies of documents submitted to verify my residency are true and correct copies of the original documents, and that any and all documents submitted have not been altered except for the redaction of dollar amounts and account numbers, which is permitted for the purposes of this Residency Verification Form. Furthermore, I recognize that falsification or omission of information could result in modification of the school or program placement for this student including withdrawal from school.

Signature of Parent/Guardian Date

I acknowledge and agree to the following: (initial each statement below):

Bellevue School District

CHANGE OF ADDRESS AND UPDATED RESIDENCY VERIFICATION FORM

Page 2 of 2 Bellevue School District 7/18/2017

DO NOT SIGN THIS FORM IF ANY OF THE STATEMENTS ARE INCORRECT. Evidence that

false information was provided will be cause for immediate revocation of the student’s school assignment and withdrawal from the District, and may lead to criminal and/or financial penalties.