Statement Of Residence - Houston Independent School District

I hereby certify that the information stated herein is true and accurate to the best of my knowledge.

I am not making this request for the purpose of obtaining some benefit or admission into a school or program of the Houston Independent School District. I understand that submitting this form with false information may constitute a violation of Section 37.10 of the Texas Penal Code. Signed this the ______________ day of ___________________, 20______ ______________________________________ ___________________________________ Please Print Name ______________________________________ ___________________________________ Campus Employee's Signature 02-106 Statement of Residence HISD Graphics —4/02

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