Admin

Custodial Statement and Agreement: Divorce, Separation, or Abandonment

ELECTION TO ATTEND SCHOOL WHERE THE PARENTS ARE DIVORCED OR SEPARATED

This agreement is prepared by the State Superintendent of Public Instruction, as required by Indiana Code 20-26-11- 3. Form I is to be signed by both parents except where the student has been abandoned by the custodial parent.

Student Information

Name: (last)_________________________________ (first)_______________________________(mi)___________ (street)________________________________(city)_________________________(state)______(zip code)_______

Last school corporation attended: __________________________________________________________________

Current School Corporation: Northwest Allen County Schools

Parent Information

Mother:

Name: (last) ________________________________(first)_________________________________(mi)__________ (street)____________________________________(city________________________(state)_____(zip code)______

Father:

Name: (last) ________________________________(first)_________________________________(mi)__________ (street)____________________________________(city________________________(state)_____(zip code)______

Parent with whom the student will live:____________________________________________________________

____________________________________ agrees to assume all the duties and be subject to all the liabilities of the parent of

(parent with whom student will live)

_______________________ with respect to dealing with the school corporation and for all other purposes under Indiana Code 20-26.

(student)

This agreement is binding from the date signed until terminated by either parent in writing.

I affirm, under the penalties for perjury, that the foregoing representations are true.


___________________________________________ ___________________________________________
Name (printed) Name (printed)
________________________________________ ________________________________________
Signature Signature
______________________________
___________________________
Date Date

Acknowledged by ______________________________________ on behalf of Northwest Allen County Schools

(name and title) (school corporation)

Date_____________________________

Sworn and subscribed before me this _________ day of ____________________, 20_____.

_______________________________ resident of _____________ County. Expires: ___________

(notary public)