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California PSA Private School Affidavit Form Sample

Private School Affidavit Form
2009-10

(Covers the period October 1, 2009 through September 30, 2010)

An asterisk (*) denotes a required field. Complete the entire form during this Internet session and select the "Submit Form" button at the end/bottom of the form to send the form electronically to the California Department of Education (CDE). If you have completed all fields, you will see a screen with a "Confirmation Number" when you "submit." An automated e-mail confirmation will be sent to the e-mail address in field #8, if supplied.

Please e-mail CDE if you have questions about this form.

NOTICE

Only full-time private schools (see Education Code [EC] Section 48222) should complete this form. A full-time private school:

• Enrolls students who are not enrolled full-time in another public or private elementary or secondary school in any of grades kindergarten through twelve;
• Provides instruction in the several branches of study required to be taught in the public schools of the state (See EC sections 51210 and 51220) to students not enrolled on a full-time basis at another private or public elementary or secondary school.

DO NOT FILE A PRIVATE SCHOOL AFFIDAVIT if this private organization:

• Provides only supplemental or tutorial instruction to students enrolled in other full-time schools;
• Provides instruction ONLY in a single subject area, such as foreign language or driver education/training;
• Provides instruction ONLY to students younger than four years, nine months;
• Does not yet have students enrolled; and/or
• Offers a high school diploma but does not provide instruction in the several branches of study outlined in EC 51220.

From EC Section 48222: This is "... a private full-time...school...[that]...offer[s] instruction in the several branches of study required to be taught in public schools of the state,...[that offers this] instruction...in English [, and that keeps]...attendance [records]..." *

Yes

School Information

1. Name of School *	Create a name for your homeschool.
2. Enter your CDE-assigned 14 digit CDS code if one was previously assigned	Homeschools do not have a code. Leave blank.
3. County in which school is located *	Select your county of residence from pull-down menu.
4. Public school district in which school is located *	Select county and then school district. Call a local school if uncertain of its district name.
5. Street Address (P.O. Box is not acceptable) *	123 Our [St.] from pulldown menu. Unit number from pulldown if an apartment or trailer.
6. City *	Your City Name and Zip Code
7. School Telephone Number *	Your Home Phone
8. School E-mail Address (primary)	No need to provide.
9. Optional E-mail Address (primary)	No need to provide.
10. Mailing Address (required *, if different from #5 above)	Answer only if this applies.
11. Mailing City (required *, if #10 has response)	Answer only if you answered #10.
12. Type of School *	Coeducational, even if you have one gender.
13. School Accommodations *	Day Only, even though your kids spend the night.
14. Do you offer Special Education instruction or services?	Leave it on "No," even if your child is special needs.
15. Range of grades offered *	Lowest: 1    Highest: 12
16. High School Diploma Offered *	Yes
17. Classification of school	Non-Religious (Even if you are religious)

Prior Year School Information

18. Has this school ever filed a Private School Affidavit under a different school name? *	Yes or No
19. Enter former name of school (if "Yes" answered to previous question)	Leave blank unless you did change the name of your homeschool.
20. Has this school changed public school districts? *	Yes or No
21. Former public school district (if "Yes" answered to previous question)	Leave blank unless you did move between California School Districts.

Statistical Information

22. 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)
23. Enrollment on a single date October 1-15, 2009 * (NOTE: Do not report pre-school enrollment; pre-schools that do not offer kindergarten should not file this PSA.)	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
24. Number of twelfth grade graduates in 2008-2009 school year *	0
25. Number of School Staff *	Staff Number Full-time Teachers 1 Part-time Teachers 0 Administrators 1 [Leave as 0 if a single parent] Other Staff 0 "Other Staff" includes instructional aides, therapists, secretaries, etc. [Only if you employ such a person, not if you just hire their services.]

Administrative Staff

26. Site Administrator *	First and Last Name
27. Site Administrator Title *	Administrator
28. Director or Principal Officer Name *	First and Last Name
29. Director or Principal Officer Position *	Director
30. Director or Principal Officer Address *	123 Our [St.] from pulldown menu. Unit number from pulldown if an apartment or trailer.
31. Director or Principal Officer City *	City, CA, and Zip Code
32. Director or Principal Officer E-mail Address	Not required. Don't give it.

43. 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 person named as Custodian of Records below maintains attendance records required by EC 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 EC Section 33190. Such records are true and accurate and are accessible at the place or through the person listed here.

33. Name of Individual who is Custodian of Records *	Title Your Name
34. Address * (Location of Records)	123 Our [St.] from pulldown menu. Unit number from pulldown if an apartment or trailer.
35. City *	Your City Name, CA, Zip Code
36. Custodian of Records E-mail Address	Not required. Don't give it.

Tax Status of School *

37. Tax-exempt, nonprofit status under Section 501(c)(3) of the U.S. Internal Revenue Code - Do NOT Check 38. Tax-exempt, nonprofit status under Section 23701d of the California Revenue and Taxation Code - Do NOT Check 39. Property tax exemption under Section 214 of the California Revenue and Taxation Code - Do NOT Check 40. None of the above - Check

Acknowledgements *

Each box is required. Checking a box indicates your understanding of the statement and your school's compliance.
Check all boxes.

	41. All Private School Affidavits are public documents viewable by the public.
	42. The Private School Affidavit must be filed by 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.
	43. Preschools should contact the Community Care Licensing Division (CCLD) of the California Department of Social Services. Contact CCLD at 916-229-4500 or contact a regional office.
	44. The Affidavit is not a license or authorization to operate a private school.
	45. The Private School Affidavit does not indicate approval, recognition, or endorsement by the state. 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 CDE, 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 EC Section 33190).
	46. 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.
	47. 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.
	48. Retain a copy of this document for a period of three years.
	49. Filing a Private School Affidavit is not equivalent to obtaining accreditation. A Private School Affidavit does not signify that any accrediting agency has made any evaluation, recognition, approval, or endorsement of the school or courses offered by the school.
	50. A private school shall not employ a person who has been convicted of a violent or serious felony or a person who would be prohibited from employment by a public school district pursuant to EC Section 44237. This school is in compliance with EC Section 44237 to the extent that it applies.
	51. The students enrolled in this private school and included in the school's enrollment total are full-time students in this school and are not enrolled in any other public or private elementary or secondary school on a full-time basis.

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.

Name of owner or other head of school *	A Parent's or Guardian's Name
Title *	Director
Telephone Number *	(408) 555-1212 Ext. XXX
Electronic Signature - Birth Month *	Month spelled out in pull down menu
Electronic Signature - Birthday *	Date in pull down menu
Electronic Signature - Question *	What is your favorite sport? color? food?
Electronic Signature - Answer *	Answer to one question above

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