FORM FOR AFFIDAVIT OF ACCEPTANCE OF PERSONAL SERVICE BY LOCAL EDUCATIONAL LIAISON FOR HOMELESS CHILDREN AND YOUTH

STATE OF NEW YORK

COUNTY OF _____________________ss.:

______________________________________________, being duly sworn, deposes and says t hat he/she is the local educational agency liaison for homeless children and youth for the _____________________________________________ School District; that on the ____day of ______________________________, 20____ he/she accepted service of the annexed ___________________________ on behalf of _______________________________________.

________________________

(Signature)

Subscribed and sworn to before

me this _______ day of _______________________, 20 __.

________________________________________________

(Signature and title of officer)