NOTE: THE FOLLOWING STATEMENT MUST BE COMPLETED AND SUBMITTED WITH PETITIONER'S REPLY OR ANY OTHER PAPERS, SUCH AS AFFIDAVITS OR EXHIBITS, PETITIONER SUBMITS IN SUPPORT OF THE APPEAL

___________________________(name of petitioner) states that he/she is the petitioner in this proceeding and is the parent or guardian of a homeless child or youth or is an unaccompanied youth as defined by §100.2(x) of the regulations of the Commissioner of Education; that he/she has read the annexed petition and any supporting affidavits or exhibits and knows the contents thereof; that the same is true to his/her knowledge except as to the matters therein stated to be alleged upon information and belief, and as to those matters he/she believes it to be true and further acknowledges that he/she is aware of the fact that, pursuant to Penal Law §175.30, a person who knowingly offers a false instrument for filing to a public official or public servant is guilty of Offering a False Instrument for Filing in the 2nd Degree, a Class A Misdemeanor.

 

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Petitioner's Signature 

 

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Date