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      FORM 4

      AFFIDAVIT IN SUPPORT OF
      WAIVER OF FILING FEE

      STATE OF NEW YORK
      STATE EDUCATION DEPARTMENT
      _____________________________________

      In the Matter of (PETITIONER'S NAME),
      on behalf of (CHILD'S NAME) from
      action of the Board of Education
      of the ______________ School
      District regarding the denial of
      admission on the basis of residency.
      _____________________________________

      STATE OF NEW YORK:
      :ss.
      COUNTY OF _______:

       

      __________________________________, being duly sworn,

      (Name)

      deposes and says:

      1. I am the petitioner in the within action and submit this affidavit in support of my application for waiver of the filing fee required by 8 NYCRR �275.9(b).

      2. Provide statement of residence and dependents:

      __________________________________________________________

      __________________________________________________________

      3. Provide statement of employment, if any, and amount and sources of all income: __________________________________________________________

      __________________________________________________________

      __________________________________________________________

      __________________________________________________________

      __________________________________________________________

       

      4. Provide statement of total monthly expenses:

      __________________________________________________________

      __________________________________________________________

      __________________________________________________________

      5. List all property held by petitioner, including real estate, personal property and bank accounts, together with the total value of each category: __________________________________________________________

      __________________________________________________________

      __________________________________________________________

      __________________________________________________________

      __________________________________________________________

      6. I am unable to pay the costs, fees and expenses necessary to pursue this appeal.

      7. No other person is beneficially interested in the outcome of this action.

      WHEREFORE, I respectfully request that the Commissioner permit me to pursue this appeal without payment of the filing fee required by 8 NYCRR �275.9(b).

      ______________________________

       

      Subscribed and sworn to

      before me this ____ day of

      _________________ 20 ____

       

      ______________________________
      (Signature of notary public)

       

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