STATEMENT OF LANDLORD TO BE COMPLETED BY OWNER/LANDLORD I/we, _____________________________ am/are the lawful owner or legal representative of the residential property

located at ___________________________ West Orange, New Jersey 07052. Dwelling Designation: Single Family ____ Two Family ____ Multi-Family ____ This residence or residential unit is currently under lease from and occupied by: ____________________________________________________________________ _____________________________________________________________________ For a period of (dates): ___________________ to ___________________ The answers provided above are absolutely true and entitles the child/children of the above tenant to a tuition-free education in the Township of West Orange. I/we understand the above information is being relied upon by the West Orange Board of Education to determine a student's residency of West Orange. I/we fully understand that any false answers provided are subject, if proven false, to punitive action. (N.J.S.A. 2C:28-2 and West Orange Municipal Ordinance #2028-05). * This document must be notarized by a Notary Public of the State of New Jersey (See below). ___________________________ ______________________________ Landlord (Signature) Landlord (Type Name) Address: ________________________________ Phone Number: _______________ City/State/Zip Code: _______________________________________________ * Sworn to and subscribed before me on this _____ day of _________ 20____ _________________________________ ___________________________ A Notary Public of the State of New Jersey My Commission Expires CERTIFICATE OF RESIDENCY - RENTER Parent/Guardian Name _________________________________________________ Address: _____________________________________ Home Phone: ____________ City, State, Zip Code: __________________________ Work Phone: ______________ Student Name(s): ___________________________________________________ ___________________________________________________ ___________________________________________________ Do you reside at the above address? Yes ____ No ____ Date Moved In: __________ Former Address: _________________________________________________________________ Appropriate Documents - Please submit Landlord's or superintendent certification, copy of lease, plus two (2) current public utility bills: ____ Certification of Landlord Utility Bills: ____ Copy of Lease ____ PSE&G ____ Rent Receipt ____ Cable/Satellite ____ Other (Specify) ____ Telephone I/we affirm that I/we am/are the custodial parent(s) and/or guardian(s) of the student(s) listed above. I/we further state that this form and the attached documentation constitute true and accurate proof that the student(s) listed reside with me/us within the Township of West Orange. If any student listed stops living with me/us, or if I/we move my/our residency, I/we will promptly notify the Board of Education in writing. I/we certify that the foregoing statements made by me/us are true. I/we am/are aware that if any of the foregoing statements made by me/us are false, I/we am/are subject to punitive action. (N.J.S.A. 2C:28-2 and West Orange Municipal Ordinance #2028-05). PLEASE SIGN AND HAVE THE FOLLOWING STATEMENTS NOTARIZED:

I certify that the information provided above is correct. I fully understand that I will be held responsible for the full payment of tuition in the following amounts if the residency requirements have been found to be falsely reported. Pre-K & Kindergarten: $12,761 Grades 1-5 $15,547 Grades 6-8 $17,173 Grades 9-12 $20,427 __________________________________________ Signature of Parent or Guardian NOTARY: Sworn to and subscribed before me on this ____ day of ________ 20 _____ ____________________________________________ Signature of Notary Public of New Jersey __________________________________________ ______________ Signature of staff member reviewing proof of residency Date CERTIFICATION OF RESIDENCY - HOMEOWNER Parent/Guardian Name __________________________________________________________ Address: _____________________________________ Telephone: _____________ City, State, Zip Code: __________________________ Cell: _____________ Work Phone: ______________ Student Name(s): _________________________________________________ _________________________________________________ _________________________________________________ Do you reside at the above address? Yes ___ No ___ Date Moved In: ___________ Former Address: ________________________________________________________ Documents required to accompany this Certification: - Please Submit: One (1) Proof of Ownership, plus two (2) current public utility bills: Proof of Ownership: Utility Bills:____ Current Mortgage Statement ____ PSE&G ____ Tax Bill ____ Cable/Satellite ____ Other ____ Telephone/Mobile Phone ____ Deed ____ Water I/we affirm that I/we am/are the custodial parent(s) and/or guardian(s) of the student(s) listed above. I/we further state that this form and the attached documentation constitute true and accurate proof that the student(s) listed reside with me/us within the Township of West Orange. If any student listed stops living with me/us, or if I/we move my/our residency, I/we will promptly notify the Board of Education in writing. I/we certify that the foregoing statements made by me/us are true. I/we am/are aware that if any of the foregoing statements made by me/us are false, I/we am/are subject to punitive action. (N.J.S.A. 2C:28-2 and West Orange Municipal Ordinance #2028-05). PLEASE SIGN AND HAVE THE FOLLOWING STATEMENTS NOTARIZED: I certify that the information provided above is correct. I fully understand that I will be held responsible for the full payment of tuition in the following amounts if the residency requirements have been found to be falsely reported. Pre-K & Kindergarten: $13,761 Grades 1-5 $15,547 Grades 6-8 $17,173 Grades 9-12 $20,427 _______________________________________ Signature of Parent or Guardian NOTARY: Sworn to and subscribed before me on this _____ day of ________ 20 _____ ____________________________________________ Signature of Notary Public of New Jersey

___________________________________________ _____________ Signature of staff member reviewing proof of residency Date

Guardian Information Legal Guardian First Name: Valada Legal Guardian Middle Name: Legal Guardian Last Name: Bishop Prefix: Ms Suffix: Primary Phone Number: (770)561-0595 Primary Phone Type: Mobile Daytime Phone Number: (770)561-0595 Daytime Phone Number Type: Mobile Email Address: [email protected] What is your relationship to the student being pre-registered?: Pending Guardian Type of Residency: Renter Guardian Address Information Street Number: 7 Street Direction: Street Name: Meeker Street Type: St Apartment Number: 2nd fl *Do not include periods/special characters for Apartment Number*: City: West Orange State: New Jersey:NJ Zip Code: 07052 Guardian Employment Information Occupation: Teacher Employer: East Orange High School Work Phone Number: (973)266-7300 Extension: Student Information Is this a re-entry after a 10 day drop?: No Student First Name: Juwan Student Middle Name: Student Last Name: Riche Suffix: What is the gender of the student?: Male Date of Birth: 12/14/2005 Was the student born in the United States of America?: Yes City of birth: Passaic State of birth: New Jersey:NJ Parent/Guardian Marital Status: Single

Student lives with: Guardian Is the student involved with the High Aptitude: Program (HAP) for gifted and talented students?: No Does this student require special services?: No Does this student have a 504/Service Agreement?: No Student Ethnicity/Race Is the student of Hispanic descent?: No : Please specify your race. (You can say 'Yes' to multiple options): American Indian/Alaska Native: No Asian: No Black: Yes Pacific Islander/Native Hawaiian: No White: No Second Legal Guardian Information Does this student have a second legal guardian that is still living?: No Student Previous School Information Will this student be entering Pre-school or Kindergarten?: Yes Did the student ever attend another school?: No Kindergarten Pupil Information 1. Does the child live with his/her parents?: No If no, please specify:: the foster mom (process of adoption) 2. Do any adults, other then the parents, live in the home?: Yes If yes, please specify:: foster mom 3. What is the child's postion in the family?: Youngest If child is from a multiple birth please indicate, twin, triplet etc.: Multiple Birth postion: 4. How many different places has the child lived in the past two years?: 0 5. Is there any home situation which may affect this child: and his/her adjustment to school?: No 6. Has your child been exposed to a language other than English?: No 7. How old was your child when he/she began to:: a. Walk unaided?: 1 b. Use understandable words?: 2 : Medical Background: 8. Have naps been necessary up to this time?: Yes 9. Does the child wear glasses?: No 10. Has your child had any ear problems?: No 11. Does your child have allergies?: Yes If yes, please explain:: change of the weather 12. Has your child had a hospital experience?: Yes If yes, please explain:: when he was with his mother 13. Is the child subject to conditions which make for classroom: emergencies? (e.g., epilepsy, fainting spells, diabetes, etc.): Yes

If yes, please explain:: broken arm 14. Does the child have any physical handicap: (orthopaedic, defect, congenital heart, etc.)?: No 15. Is it necessary for your child to take medication: at home or during school hours?: Yes If yes, please explain:: he has asthma PLEASE NOTE: Any medication given at school must be administered by the school nurse and with a doctor's note.: : Growth and Development: 16. Does the child have any type of speech difficulty: (stuttering, articulation, etc.)?: No 17. Does your child speak in complete sentences?: No 18. What is the child's attitude toward school?: Uncertain 19. What name will your child use in school?: Juwan 20. Has your child had experience with:: Crayons: Some Paint: Some Scissors:: Little 21. Is your child?: Right Handed 22. Does your child take care of toilet habits independently?: Always 23. Does the child dress independently?: Tie Shoes: Yes Button buttons?: Yes Zip zippers?: Yes Put on boots?: Yes 24. Does your child have any special interests that we should know: about (watching TV, playing with other children, music, art, etc.)?: Yes If yes, please explain: tv and puzzles 25. Does your child accept changes in routines?: Yes 26. Does your child have any special fears: (dreams, nightmares, phobias, etc.)?: Yes If yes, please explain: he's having counseling to help him to understand adoption 27. Describe any anxieties your child might have:: 28. Does your child show interest and curiosity concerning: printed words and letters? (choose one): Some Interest 29. Does someone read to the child?: Yes How often?: in the daycare 30. Please add any other information that may be important: for the school to know regarding your child:: Health History Information Chicken Pox: No Allergies: Yes List Allergens and types of reactions below:: change of the weather, no milk Asthma/Reactive Airway: Yes Describe symptoms and treatment below:: medication as needed Diabetes: No Ear Infections: No Hearing Difficulties: No Eyeglasses/Contacts: No Hospitalizations: No

Serious Injury: No Surgery: No Seizure/Convulsion: No Currently on Medication: No Does the student have any other conditions not mentioned above?: No Home Language Survey 1. What language did the child first speak?: English 2. What language does the parent/guardian use: most often when speaking to the child?: English 3. What language does the child use most often: when speaking to his/her parent/guardian?: English 4. What language does the child use most often: when speaking to his/her brothers and sisters?: English 5. What language does the child use most: often when speaking to other relatives?: English 6. What language does the child use most: often when speaking to his/her friends?: English 7. Did your child enter the USA within the past: year from a non-English speaking country?: No Media Release/Child Internet Protection Act (CIPA) I hereby give permission for the West Orange Public Schools to: release photographs, videotapes and/or the name of my child to: the media. I understand this will not be used for commercial: purposes. Should we change our mind in the future, we will: contact the school our child attends.: No Web site Consent I/We GRANT permission for a photo/image that includes: this student without any other personal identifiers to be: published on the school and/or district's public Internet site.: No : I/We GRANT permission for this student's photo/image and name: to be published on the school and/or district's public Internet site,: but the name will not be associated with the studnet's image.: No : I/We DO NOT GRANT permission for this student's: photo/image or name to be published on the: school and/or district's public Internet site.: Yes Alternate Contact Alternate Contact First Name: Valada Alternate Contact Last Name: Bishop Street Address: 7 Meeker st City: West Orange State: New Jersey Zip Code: 07052 Home Phone Number: (770)561-0595

Relationship to the student: Other Please specify: foster mom Would you like to add an additional alternate contact?: No Guardian Information Legal Guardian First Name: Valada Legal Guardian Middle Name: Legal Guardian Last Name: Bishop Prefix: Ms Suffix: Primary Phone Number: (770)561-0595 Primary Phone Type: Mobile Daytime Phone Number: (770)561-0595 Daytime Phone Number Type: Mobile Email Address: [email protected] What is your relationship to the student being pre-registered?: Pending Guardian Type of Residency: Renter Guardian Address Information Street Number: 7 Street Direction: Street Name: Meeker Street Type: St Apartment Number: 2nd fl *Do not include periods/special characters for Apartment Number*: City: West Orange State: New Jersey:NJ Zip Code: 07052 Guardian Employment Information Occupation: Teacher Employer: East Orange High School Work Phone Number: (973)266-7300 Extension: Student Information Is this a re-entry after a 10 day drop?: No Student First Name: Nazik Student Middle Name: Student Last Name: Holder Suffix: What is the gender of the student?: Male Date of Birth: 11/26/2007 Was the student born in the United States of America?: Yes City of birth: Passic State of birth: New Jersey:NJ Parent/Guardian Marital Status: Single Student lives with: Guardian Is the student involved with the High Aptitude:

Program (HAP) for gifted and talented students?: No Does this student require special services?: Yes What school district is your plan from?: P.leasantdale School in WOrange Does this student have a 504/Service Agreement?: Yes Student Ethnicity/Race Is the student of Hispanic descent?: No : Please specify your race. (You can say 'Yes' to multiple options): American Indian/Alaska Native: No Asian: No Black: Yes Pacific Islander/Native Hawaiian: No White: No Second Legal Guardian Information Does this student have a second legal guardian that is still living?: No Student Previous School Information Will this student be entering Pre-school or Kindergarten?: Yes Did the student ever attend another school?: No Kindergarten Pupil Information 1. Does the child live with his/her parents?: No If no, please specify:: foster mom 2. Do any adults, other then the parents, live in the home?: Yes If yes, please specify:: foster mom 3. What is the child's postion in the family?: Youngest If child is from a multiple birth please indicate, twin, triplet etc.: Multiple Birth postion: 4. How many different places has the child lived in the past two years?: 0 5. Is there any home situation which may affect this child: and his/her adjustment to school?: No 6. Has your child been exposed to a language other than English?: No 7. How old was your child when he/she began to:: a. Walk unaided?: 1 b. Use understandable words?: had trouble early : Medical Background: 8. Have naps been necessary up to this time?: Yes 9. Does the child wear glasses?: No 10. Has your child had any ear problems?: No 11. Does your child have allergies?: Yes If yes, please explain:: change of weather 12. Has your child had a hospital experience?: No 13. Is the child subject to conditions which make for classroom: emergencies? (e.g., epilepsy, fainting spells, diabetes, etc.): No 14. Does the child have any physical handicap: (orthopaedic, defect, congenital heart, etc.)?: No

15. Is it necessary for your child to take medication: at home or during school hours?: Yes If yes, please explain:: asthma medication when needed PLEASE NOTE: Any medication given at school must be administered by the school nurse and with a doctor's note.: : Growth and Development: 16. Does the child have any type of speech difficulty: (stuttering, articulation, etc.)?: No 17. Does your child speak in complete sentences?: Yes 18. What is the child's attitude toward school?: Uncertain 19. What name will your child use in school?: Nazik 20. Has your child had experience with:: Crayons: Little Paint: Little Scissors:: Little 21. Is your child?: Right Handed 22. Does your child take care of toilet habits independently?: Never 23. Does the child dress independently?: Tie Shoes: No Button buttons?: No Zip zippers?: Yes Put on boots?: Yes 24. Does your child have any special interests that we should know: about (watching TV, playing with other children, music, art, etc.)?: Yes If yes, please explain: tv music 25. Does your child accept changes in routines?: No 26. Does your child have any special fears: (dreams, nightmares, phobias, etc.)?: No 27. Describe any anxieties your child might have:: 28. Does your child show interest and curiosity concerning: printed words and letters? (choose one): Some Interest 29. Does someone read to the child?: Yes How often?: daycare 30. Please add any other information that may be important: for the school to know regarding your child:: Health History Information Chicken Pox: No Allergies: Yes List Allergens and types of reactions below:: change of weather Asthma/Reactive Airway: Yes Describe symptoms and treatment below:: change in weather, no milk Diabetes: No Ear Infections: No Hearing Difficulties: No Eyeglasses/Contacts: No Hospitalizations: No Serious Injury: No Surgery: No Seizure/Convulsion: No Currently on Medication: No

Does the student have any other conditions not mentioned above?: No Home Language Survey 1. What language did the child first speak?: English 2. What language does the parent/guardian use: most often when speaking to the child?: English 3. What language does the child use most often: when speaking to his/her parent/guardian?: English 4. What language does the child use most often: when speaking to his/her brothers and sisters?: English 5. What language does the child use most: often when speaking to other relatives?: English 6. What language does the child use most: often when speaking to his/her friends?: English 7. Did your child enter the USA within the past: year from a non-English speaking country?: No Media Release/Child Internet Protection Act (CIPA) I hereby give permission for the West Orange Public Schools to: release photographs, videotapes and/or the name of my child to: the media. I understand this will not be used for commercial: purposes. Should we change our mind in the future, we will: contact the school our child attends.: No Web site Consent I/We GRANT permission for a photo/image that includes: this student without any other personal identifiers to be: published on the school and/or district's public Internet site.: No : I/We GRANT permission for this student's photo/image and name: to be published on the school and/or district's public Internet site,: but the name will not be associated with the studnet's image.: No : I/We DO NOT GRANT permission for this student's: photo/image or name to be published on the: school and/or district's public Internet site.: Yes Alternate Contact Alternate Contact First Name: Valada Alternate Contact Last Name: Bishop Street Address: 7 Meeker st City: West Orange State: New Jersey Zip Code: 07052 Home Phone Number: (770)561-0595 Relationship to the student: Other Please specify: foster mom Would you like to add an additional alternate contact?: No