Affidavit Verifying Informal Kinship Care Relationship

1. I, the undersigned, am over eighteen (18) years of age and competent to testify to the facts and matters set forth herein.




2. ____________ (name of child), whose date of birth is ____________, is living with me because of the following serious family hardship: (check each that is applicable)
   _____ death of father/mother/legal guardian
   _____ serious illness of father/mother/legal guardian
   _____ drug addiction of father/mother/legal guardian
   _____ incarceration of father/mother/legal guardian
   _____ abandonment by father/mother/legal guardian
   _____ assignment of a parent or legal guardian of a child to active military duty
   

3. The name and last known address of the child's parent(s) or legal guardian is:
   _____________________________
   
   _____________________________
   
   _____________________________
   
   _____________________________
   


4. My kinship relation to the child is ____________________
   


5. My address is:
   _____________________________
   
   _____________________________
   
   _____________________________
   
   _____________________________
   


6. I assumed informal kinship care of this child for 24 hours days and 7 days a week on
   _____________________(day/month/year)



7. The name and the address of the last school that the child attended is:
   ___________________________________________________________________________
   ___________________________________________________________________________
   


8. The county superintendent may verify the facts contained in the foregoing affidavit and conduct an audit on a case-by-case basis after the child has been enrolled in the county public school system. If the county superintendent discovers fraud or misrepresentation, the child shall be removed from the county public school system roll.
   


9. I solemnly affirm under the penalties of perjury that the contents of the foregoing are true to the best of my knowledge, information, and belief.
   
   ______________________________________                    _____________________
   Signature of affiant                                                                               (day/month/year)
   


10. Any person who willfully makes a material misrepresentation in this affidavit shall be subject to a penalty payable to the county for three times the pro rata share of tuition for the time the child fraudulently attends public school in the county.

  Source: Maryland State Law Library (MSLL)                                                                         Date of last review: 01/29/08 (PLL/M.A.J.)