Send documents to: Connections Academy By fax: 800-887-6590 By mail: 1001 Fleet St.

, Fifth Floor, Baltimore, MD 21202 Questions? Call 800-382-6010.

Proof of Residency
You are required to submit one of the following documents to prove that the student you are enrolling meets state residency requirements and to verify the students address for shipping school-provided materials. The document you submit must be in the name of the parent/legal guardian with whom the student resides. You only need to submit one proof of residency document per household, if all students in the household reside with the same parent/legal guardian. If none of the acceptable items listed below is in the parent/legal guardians name, then you may still enroll the students by submitting an acceptable proof of residency document in the name of the person with whom you and your students reside (i.e., the residence owner/leaseholder) and by having this person complete the attached Notarized Statement of Shared Domicile form.

The following items are acceptable at all Connections Academy schools for proof of residency: Utility Bills: Please send a gas, electric, sewage, or water bill from the last 60 days showing the service address and identifying the parent/legal guardian as the account holder. Shut-off or disconnect notices and propane delivery statements are not acceptable proof of residency. Mortgage Statement: Please send a statement from the last 60 days that identifies the physical address of the parent/legal guardian as the mortgaged property address and identifies the parent/legal guardian as the borrower. Lease Agreement: Please send a copy of the signed lease agreement from a rental company, or similar agent, showing current terms with the name and address of the parent/guardian.

The following exceptions are identified by the school where these additional items are considered acceptable for proof of residency: Arizona Connections Academy: A copy of the most recent state income tax return for the parent/legal guardian containing his or her physical address. Jackson Hole Connections Academy: A copy of the Wyoming state identification card for the parent/legal guardian. Nevada Connections Academy: A copy of the Nevada state identification card for the parent/legal guardian. Ohio Connections Academy: A copy of the parent/legal guardians most recent phone, cable, or Internet bill (from the last 60 days); voter notification card; property tax statement; bank statement; or pay check statement. These documents must list the address provided for enrollment. NOT ACCEPTABLE: Notarized statements, drivers licenses, state identification cards, and disconnect/final/shut-off notices. South Carolina Connections Academy: A copy of the South Carolina state identification card for the parent/legal guardian.

2010 Connections Academy, LLC.

Questions? Call 800-382-6010.

www.ConnectionsAcademy.com

Send documents to: Connections Academy By fax: 800-887-6590 By mail: 1001 Fleet St., Fifth Floor, Baltimore, MD 21202 Questions? Call 800-382-6010.

Notarized Statement of Shared Domicile

Parent/Legal Guardian: If none of the acceptable proof of residency documents for the students is in your name, have the resident owner/leaseholder complete and sign this form and submit it with an acceptable proof of residency in his or her name. This form must be notarized. One proof of residency is required per household. Acceptable proof of residency documents include a most recent gas, water, or electric bill that identifies the residence owner/leaseholder and shows the service location or a copy of a most recent mortgage statement or a signed current lease agreement. NOTE: Notarized Statements of Shared Domicile are unacceptable proof of residency in the state of Ohio.

Statement of Verification
Please identify the first and last names of the parents/guardians and children residing with you.

The parents/guardians and children listed above currently reside with me at the following address:
Street Address City Apartment/Unit # County State ZIP Code

Signature of Resident Owner/Leaseholder

The person named on the proof of residency must sign below for this form to be valid. By signing below, I certify that the adult(s) and child(ren) listed above currently reside with me at the above-listed address and that this information is true to the best of my knowledge.

Resident Owner/Leaseholders Name (Please print)

Resident Owner/Leaseholders Signature

Date

Phone

Signature of Notary Public

The Notary Public witnessing this form must complete this section.
Notary Public Name Notary Commission Expiration Date Notary Public Signature Place Notary Stamp here: Date

2010 Connections Academy, LLC.

Questions? Call 800-382-6010.

www.ConnectionsAcademy.com