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California Private School Affidavit Sample

Private School Affidavit Form Sample

2018-19

(Covers the period October 1, 2018 through September 30, 2019)

An asterisk (*) denotes a required field. Complete the entire form during this Internet session and select the “Submit Form” button at the end/bottom of the form to send the form electronically to the California Department of Education (CDE). If you have completed all fields, you will see a screen with a “Confirmation Number” when you “submit.” An automated e-mail confirmation will be sent if an e-mail address is entered in #9.

IMPORTANT WEB BROWSER NOTE: When your Web browser displays an alert prompt, do NOT check the box next to ‘Prevent this page from creating additional dialogs.’ If you do, you will need to restart your Web browser and start over.

Please send an e-mail to e-mail CDE if you have questions about this form.

NOTICE

Only full-time private schools (see Education Code [EC] Section 48222) should complete this form. A full-time private school:

  • Enrolls students who are not enrolled full-time in another public or private elementary or secondary school in any of grades kindergarten through twelve;
  • Provides instruction in the several branches of study required to be taught in the public schools of the state (See EC sections 51210 and 51220) to students not enrolled on a full-time basis at another private or public elementary or secondary school.

DO NOT FILE A PRIVATE SCHOOL AFFIDAVIT if this private organization:

  • Provides only supplemental or tutorial instruction to students enrolled in other full-time schools;
  • Provides instruction ONLY in a single subject area, such as foreign language or driver education/training;
  • Provides instruction ONLY to students younger than four years, nine months;
  • Does not yet have students enrolled; and/or
  • Offers a high school diploma but does not provide instruction in the several branches of study outlined in EC 51220.
From EC Section 48222: This is “… a private full-time…school…[that]…offer[s] instruction in the several branches of study required to be taught in public schools of the state,…[that offers this] instruction…in English [, and that keeps]…attendance [records]…” * Yes – from the drop-down menu
A Private School Affidavit cannot be filed if the answer to this question is NO.

School Information

1. Name of School * Create a name for your homeschool before you start this form!
2. Enter your CDE-assigned 14 digit CDS code if one was previously assigned Homeschools do not have a code. Leave blank.
3. County in which school is located * Select your county of residence from pull-down menu.
4. Public school district in which school is located * Use the district name lookup tool to enter information into the box. You may need to configure your Web browser to allow popup windows for this site. The selection of the district in which your school is located is important. If you are not sure which district you are in, call your County Office of Education for assistance.
5. Street Address (P.O. Box is not acceptable) * 123 Our [St.]  Include unit number if from an apartment or trailer, or any other unit type you normally use.
6. City * Your City Name, State, and Zip Code (Add 4-digit extension if you know it.)
7. School Telephone Number * Your Home Phone
8. Optional School Fax Number No need to provide.
9. School E-mail Address (primary)* Required to provide. Use your own. An automated e-mail confirmation will be sent if an e-mail address is entered.
10. Optional E-mail Address (primary) No need to provide.
11. Optional School Web Site Address Optional.
12. Mailing Address Only if different from #5 above)
13. Mailing City Required *, only if #12 has response
14. Type of School * Coeducational, even if you have only a child or children of one gender.
15. School Accommodations * Day Only, even though your kids spend the night. Boarding schools must meet certain building codes, etc.
16. This school is a certified Nonpublic, Nonsectarian School No. Even if your children have exceptional needs, you do not need to be certified.
(more information)
17. Grade Span offered * Lowest: 1    Highest: 12    No need to file for Kindergarten UNLESS you have pulled your child after enrolling in K.
18. High School Diploma Offered * Yes
19. Classification of school Non-Religious (Even if you are religious)

Prior Year School Information

20. Has this school ever filed a Private School Affidavit under a different school name? * Yes or No, whichever is true.
21. Enter former name of school (if “Yes” answered to previous question) Leave blank unless you did change the name of your homeschool.
22. Has this school changed public school districts? * Yes (If you moved, or city redistricted your school) or No, which is more likely.
23. Former public school district (if “Yes” answered to previous question) Leave blank unless you did move between California School Districts.

Statistical Information

24. Range of students’ ages *
(Youngest may be no younger than 4 years and 9 months)
Youngest: 5 Years, 1 months. They forgot to update the form when they changed compulsory date to Sept. 1.   Oldest: 17 (If one child, put same data in each box)
25. Specify the enrollment counts by grade on or around the date the affidavit is filed. *
(NOTE: Do not report pre-school enrollment; pre-schools that do not offer kindergarten should not file this PSA.)
Grade Number of Pupils
Kindergarten 0
First Grade 0
Second Grade 0
Third Grade 0
Fourth Grade 0
Fifth Grade 0
Sixth Grade 0
Seventh Grade 0
Eight Grade 0
Ninth Grade 0
Tenth Grade 0
Eleventh Grade 0
Twelfth Grade 0
Ungraded Elementary 1 or more children or
Ungraded Secondary 1 or more children
Total Enrollment Total children
26. Number of twelfth grade graduates in 2016-2017 school year * 0, or the number you graduated last spring.
27. Number of School Staff *
Staff Number
Full-time Teachers 1
Part-time Teachers 0
Administrators 1 [Leave as 0 if a single parent]
Other Staff 0

“Other Staff” includes instructional aides, therapists, secretaries, etc. [Only if you employ such a person, not if you just hire their services.]

Administrative Staff

28. Site Administrator * Title, First and Last Name
29. Site Administrator Title * Head of School, Headmaster, Director are all common Private School titles.
30. Site Administrator E-mail Address * Administrator’s email address required
31. Director or Principal Officer Name * Title, First and Last Name of other adult in household, if 2
32. Director or Principal Officer Position * Director
33. Director or Principal Officer Address * 123 Our [St.], Unit Number, if used.
34. Director or Principal Officer City * City, CA, and Zip Code
35. Director or Principal Officer E-mail Address Not required. Don’t give it.

School Records

The person named as Custodian of Records below maintains attendance records required by EC Section 48222 and the records of courses of study, names, addresses, and educational qualifications of the faculty, as required by subdivisions (f)(2) and (3) of EC Section 33190. Such records are true and accurate and are accessible at the place or through the person listed here.

 

36. Name of Individual who is Custodian of Records * Title, First and Last Name
37. Custodian of Records Address * 123 Our [St.], Unit number, if used.
38. Custodian of Records City * Your City Name, CA, Zip Code
39. Custodian of Records E-mail Address Not required. Don’t give it.

 

Tax Status of School *

40. Tax-exempt, nonprofit status under Section 501(c)(3) of the U.S. Internal Revenue Code Do NOT Check
41. Tax-exempt, nonprofit status under Section 23701d of the California Revenue and Taxation Code Do NOT Check
42. Property tax exemption under Section 214 of the California Revenue and Taxation Code Do NOT Check
43. None of the above Check

Acknowledgements and Statutory Notices *

Each box is required. Checking a box indicates your understanding of the statement and your school’s compliance.
Check all boxes.

44. All Private School Affidavits are public documents viewable by the public.
45. The Private School Affidavit must be filed by persons, firms, associations, partnerships, or corporations offering or conducting full-time day school at the elementary or high school level for students between the ages of six and eighteen years of age.
46. Preschools should contact the Community Care Licensing Division (CCLD) of the California Department of Social Services. Contact CCLD at 916-229-4530 or contact a regional office.
47. The Affidavit is not a license or authorization to operate a private school.
48. The Private School Affidavit does not indicate approval, recognition, or endorsement by the state. Filing of this Affidavit shall not be interpreted to mean, and it shall be unlawful for any school to expressly or impliedly represent by any means whatsoever, that the State of California, the Superintendent of Public Instruction, the State Board of Education, the CDE, or any division or bureau of the Department, or any accrediting agency has made any evaluation, recognition, approval, or endorsement of the school or course unless this is an actual fact (see EC Section 33190).
49. Private school authorities are responsible for initiating contact with the appropriate local authorities (city and/or county) regarding compliance with ordinances governing health, safety and fire standards, business licensing, and zoning requirements applicable to private schools.
50. When a school ceases operation, every effort should be made to give a copy of pupils’ permanent records to parents or guardians. If records cannot be given to the parents or guardians, it is recommended that the school’s custodian of records retain the records permanently so that former pupils may obtain copies when needed for future education, employment, or other purposes.
51. Retain a copy of this document for a period of three years.
52. Filing a Private School Affidavit is not equivalent to obtaining accreditation. A Private School Affidavit does not signify that any accrediting agency has made any evaluation, recognition, approval, or endorsement of the school or courses offered by the school.
53. A private school shall not employ a person who has been convicted of a violent or serious felony or a person who would be prohibited from employment by a public school district pursuant to EC Section 44237. This school is in compliance with EC Section 44237 to the extent that it applies.
54. The students enrolled in this private school and included in the school’s enrollment total are full-time students in this school and are not enrolled in any other public or private elementary or secondary school on a full-time basis.

 

Electronic Signature

By submitting this form and the electronic signature attached hereto, I declare under penalty of perjury and the laws of the State of California that I am the owner or other head of the school, and the information contained herein is true, accurate, and complete.

Name of owner or other head of school * A Parent’s or Guardian’s Name
Title * Director
Telephone Number * (408) 555-1212 Ext. XXX
Electronic Signature – Birth Month * Month spelled out in pull down menu
Electronic Signature – Birthday * Date in pull down menu
Electronic Signature – Question * What is your favorite sport? color? food?
Electronic Signature – Answer * Answer to one question above

Please print and retain for your records the image on your computer screen after you click the Submit Form button. This is your school’s 2018-19 Private School Affidavit with Confirmation Number.

I recommend saving one image copy (PDF) to your computer or thumb drive, if not using your own computer or intend to travel extensively, and making two (2) printed copies, one to be carefully preserved in a file or binder, the other as a “traveling” copy when needed outside your home. A pdf copy could be kept on a Smart Phone with the appropriate document reader app also installed.

More California Homeschool Resources

Associations | Events | Field Trips | Publications | Resources

Forming a Private School | Laws | Legal Information | Legislation Watch
Private School Affidavit | PSA Sample

About Charter Schools | Charter School List


Private School Satellite Programs | Public ISPs
Online Support | Support Groups | Support Group Lists

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