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New York State Education Department

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.

__________________________________ Petitioner's Signature

____________________

New York State Education Building

89 Washington Avenue

Albany, NY 12234

NYSED General Information: (518) 474-3852

ACCES-VR: 1-800-222-JOBS (5627)

TASC (formerly GED): (518) 474-5906

New York State Archives: (518) 474-6926

New York State Library: (518) 474-5355

New York State Museum: (518) 474-5877

Office of Higher Education: (518) 486-3633

Office of the Professions: (518) 474-3817

P-12 Education: (518) 474-3862

Office of Counsel (link sends e-mail)

Adult Education Vocational Services (link sends e-mail)

New York State Archives (link sends e-mail)

New York State Library (link sends e-mail)

New York State Museum (link sends e-mail)

Office of Higher Education (link sends e-mail)

Office of the Professions (link sends e-mail)

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The final report should appear as shown in Figure 5.

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