Declaration of Residency

First Name(required)
Last Name(required)
Address(required)
City (required)
State(required)
Zip(required)
I affirm that I am a resident of: (Town of Residency)
In Vermont as of (MM/DD/YYYY)
I can provide the foloowing evidence of my residency (check all that apply)
I have purchased a home within the school boundary & occupy it as my primary residence I have leased a dwelling within the town & occupy it as my primar residence My primary residence is with a family whose home is in the above referenced town Other
If other, please explain.
As proof of my residence, I have presented ONE of the foloowing:
Purchase agreement for home or Warranty Deed Lease Agreement Other acceptable documentation verifying my primary residence.
I do solemly declare that the information I have given above is true and correct to the best of my knowledge and belief. I have read the Vermont statute (13 V.S.A. 3016) which calls for possible fines and imprisonment for making false declarations (on bottom of form)
Signature

Source: Vermont Statutes/TITLE 13 Crimes and Criminal Procedure / PART 1 Crimes /CHAPTER 67. PUBLIC JUSTICE & PUBLIC OFFICERS/ 3016. False Claim.

a) A person shall not, in any matter within the jurisdiction of a supervisory union school district or of any commission, board, department or agency of the state or a county or municipality, with intent to defraud, falsify, conceal or cover up by any trick, scheme or device a material fact, or with intent to defraud make any false, fictitious or fraudulent claim or representation as to a material fact, or with intent to defraud make or use any writing or document knowing the same to contain any false, fictitious or fraudulent claim or entry as to a material fact.
b) A person who violates this section shall, if the prohibited act results in no loss to a government entity or benefit to the person or results in a loss to a government entity or benefit to the person of less than $500.00 in value, be imprisoned not more than two years or fined not more than $5,000.00, or both. A person who violates this section shall, if the prohibited act results in a loss to any governmental entity or a benefit to the person of $500.00 or more in value, whether by a single act or by a common scheme or course of conduct involving one or more transactions, be imprisoned not more than five years, or fined not more than $10,000.00, or both.
c) A person who commits an at punishable under subsection (q) or (b) of section 2581 of Title 33 may not be prosecuted under this section.
Added 1987, No. 48, 6

Bennington-Rutland Supervisory Union
6378 VT Route 7A
Sunderland, Vermont, 05250-8427
Phone: 802-362-2452,
Fax:802-362-2455

Long Trail School

Declaration of Residency

Giving To LTS