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California R4 Private School Affidavit
Form Sample
Private School Affidavit Confirmation
Fall 2007
(covers the period October 1, 2007 through September 30, 2008)
Click on the "Submit Form" button at the bottom
of the form to submit the form to the California Department of
Education (CDE). An asterisk ("*") denotes fields required
to submit the form. You must complete the entire form during
this browser session.
Please e-mail
CDE if you have questions about this form.
Statutory Notices *
(Check the boxes below
to acknowledge your understanding of each Notice.) Check
all boxes.
|
1. All Private School Affidavits are public documents viewable
by the public. |
|
2. The Private School Affidavit is for persons, firms, associations,
partnerships, or corporations offering or conducting full-time
day school at the elementary or high school level for students
between the ages of six and eighteen years of age. (Note: Preschools
should contact the Community Care Licensing Division (CCLD) of
the California Department of Social Services. Contact CCLD at
916-229-4530 or Community Care Licensing Division.) |
|
3. The Affidavit is not a license or authorization to operate
a private school. |
|
4. Filing does not grant state approval, recognition, or
endorsement. Filing of this Affidavit shall not be interpreted
to mean, and it shall be unlawful for any school to expressly
or impliedly represent by any means whatsoever, that the State
of California, the Superintendent of Public Instruction, the
State Board of Education, the State Department of Education,
or any division or bureau of the Department, or any accrediting
agency has made any evaluation, recognition, approval, or endorsement
of the school or course unless this is an actual fact (see Education
Code Section 33190). |
School Information
Classification of School *
| 27.
Classification of school |
Non-Religious (Even
if you are religious) |
Statistical Information
28. Range of students'
ages *
(Youngest may be no younger than 4 years and 9 months) |
Youngest: 17 Years, 3 months Oldest:
17 (If one child, put same data in each box) |
|
29. Enrollment on a single date October 1-15, 2007
*
(NOTE: If you identified yourself as a certified nonpublic
nonsectarian school (NPS) in number 6, please list only your
privately funded students.)
|
| Grade |
Number of Pupils |
| Kindergarten |
0 |
| First Grade |
0 |
| Second Grade |
0 |
| Third Grade |
0 |
| Fourth Grade |
0 |
| Fifth Grade |
0 |
| Sixth Grade |
0 |
| Seventh Grade |
0 |
| Eight Grade |
0 |
| Ninth Grade |
0 |
| Tenth Grade |
0 |
| Eleventh Grade |
0 |
| Twelfth Grade |
0 |
| Ungraded Elementary |
0 |
| Ungraded Secondary |
1 |
| Total Enrollment |
1 |
|
| Number of Twelfth
Grade Graduates in 2006-2007 School Year * |
0 |
| 30. Number of School
Staff * |
| Staff |
Number |
| Full-time Teachers |
1 |
| Part-time Teachers |
0 |
| Administrators |
1 |
| Other Staff |
0 |
"Other Staff" includes instructional aides,
therapists, secretaries, etc. |
Director and Principal Officer
| 31.
Name * |
Mrs. Your Name |
| 32.
Position * |
Director |
| 33.
Address * |
123 Our St. [Suite 4 or leave blank] |
| 34.
City * |
Your City Name |
| 35.
E-mail Address |
yourname@ourhouse.com |
| 36.
Name |
|
| 37.
Position |
|
| 38.
Address |
|
| 39.
City |
|
| 40.
E-mail Address |
|
Tax Status of School *
|
41. Tax-exempt, nonprofit status under Section 501(c)(3) of
the U.S. Internal Revenue Code - Do NOT Check
Tax-exempt, nonprofit status under Section 23701d of the California
Revenue and Taxation Code - Do NOT Check
Property tax exemption under Section 214 of the California
Revenue and Taxation Code - Do NOT Check
None of the above - Check
|
|
42. NDSL Cancellation * - Full-time teachers in private nonprofit schools having concentrations of students from low-income families may have National Direct Student Loans (NDSL) canceled. (Title 20, United States Code, section 1087ee; Title 34, Code of Federal Regulations, section 674.53.) If you believe your school can qualify in either or both categories, select "Yes;" otherwise, select "No."
Check No
|
School Records
The attendance records required by Education Code
Section 48222 and the records of courses of study, names, addresses,
and educational qualifications of the faculty, as required by
subdivisions (f)(2) and (3) of Education
Code Section 33190, are maintained by the person and
at the place listed here and are true and accurate.
| 43.
Name of Individual who is Custodian of Records * |
Mrs. Your
Name |
| 44.
Address * (Location of Records) |
123 Our St. |
| 45.
City * |
Your City Name |
| 46.
E-mail Address |
yourname@ourhouse.com |
Acknowledgements *
(Check the boxes below
to acknowledge your understanding of each statement.) Check all boxes.
|
47. Private school authorities are responsible
for initiating contact with the appropriate local authorities
(city and/or county) regarding compliance with ordinances governing
health, safety and fire standards, business licensing, and zoning
requirements applicable to private schools. |
|
48. When a school ceases operation, every
effort should be made to give a copy of pupils' permanent records
to parents or guardians. If records cannot be given to the parents
or guardians, it is recommended that the school's custodian of
records retain the records permanently so that former pupils
may obtain copies when needed for future education, employment,
or other purposes. |
|
49. Make a copy of this document for your
records and retain for a period of three years. |
|
50. Filing an affidavit does not mean that
any accrediting agency has made any evaluation, recognition,
approval, or endorsement of the school or course. |
|
51. This school is in compliance with California
Education Code Section 44237 to the extent that it applies. |
Electronic Signature
By submitting this
form and the electronic signature attached hereto, I declare
under penalty of perjury and the laws of the State of California
that I am the owner or other head of the school, and the information
contained herein is true, accurate, and complete.
I will maintain a hard copy of this complete document, to
be produced on demand, for a period of three years.
| Name of Person
Preparing Form |
Your Name (unless someone else) |
| Title |
Director |
| Telephone
Number |
(408) 555-1212 |
| Electronic
Signature - Birth Month |
Month spelled out |
| Electronic
Signature - Birthday |
Day as single or double digit |
| Electronic
Signature - Question |
What is your favorite sport? color? food? |
| Electronic
Signature - Answer |
Answer to one question |
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