CORONA-NORCO UNIFIED SCHOOL DISTRCT PUPIL SERVICES DEPARTMENT VERIFICATION OF BIRTH DATE AFFIDAVIT u » hereby declare that I am the parent, guardian, custodian or caregiver of » a minor. I further declare that I am unable to obtain a certified copy of the birth record, the statement from the local Registrar or County Recorder certifying the date of birth of , & baptism certificate duly attested, or a passport. I further declare and certify that said child was born on I ! in Month Day Year the City of, County of, State of a and that his/her true and correct surname is or that said child’s surname, as herein stated, correctly reflects the given surname at birth or that his/her name has been changed by a court order and the sumame shown here is that ordered by the court, 1 declare under penalty of perjury that the foregoing is true and correct. DATE, PRINTED NAME SIGNATURE RELATIONSHIP TO STUDENT. Corona, California Birth Parents Information: Father: First Name Middle ital Tast Name Mother: First Name Midale intial Maiden Name Tast Name Witnessed by Centralized Registration Staff Registrar Date NOTICE: _IN THE EVENT THAT IS DETERMINED THAT FALSE, MISLEADING, OR DELIBERATE OMISSION OF INFORMATION IS USED TO ESTABLISH RESIDENCE AND SECURE REGISTRATION IN THE DISTRICT, SUCH REGISTRATION SHALL BE CONSIDERED NULL AND VOID,