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Fòm Pou Deklarasyon Sou Sèman Pou Akseptasyon Sèvis Pèsonèl Lyezon Edikasyonèl Lokal Bay Pou Timoun Ak Jèn Moun Ki Sanzabri (Form For Affidavit Of Acceptance Of Personal Service By Local Educational Liaison For Homeless Children And Youth-Haitian Creole)

ETA NEW YORK

KONTE _____________________ss.:

 

______________________________________________, ki fè sèman kòmsadwa, depoze epi di li se lyezon ajans edikasyon lokal pou timoun ak jèn moun ki sanzabri pou Distri Lekòl_____________________________________________; nan dat ____yèm jou mwa ______________________________, 20____ li te aksepte sèvis ___________________________ ki anekse a nan dat _______________________________________.

 

______________________________
(Siyati)

 

Siyen epi fè sou sèman devan mwen nan dat____yèm jou mwa ________ 20 ______

 

______________________________
(Siyati notè piblik la)