Prince Edward County Middle 
                                                                          35 Eagle Dr.
          Farmville, VA 

CHANGE OF ADDRESS FORM
(Please print)

   Name of Student(s)             Grade(s)               Birth Date(s)

 ---------------------------------------                   ------------------	                 -------------------------

---------------------------------------                    -----------------		 -------------------------

 ---------------------------------------	      	 -----------------	  	   -------------------------

Parent’s Name 	

Old Address 	

New Address  	

New Phone #(s)                                 ,                                 ,  	

It is understood that the information provided by the undersigned is accurate. Under §22.1-264.1 of the Code of Virginia, any person who knowingly makes a false statement concerning the residency of a child for the purposes of avoiding tuition or enrollment in a school outside the student’s attendance zone, shall be guilty of a Class 4 misdemeanor.

Parent’s Signature 	

Date 	

To ensure that you continue to receive important academic information and related mailings from your school, attach a copy of one of the following:

A signed lease, bill, deed, settlement papers, mortgage statement or deed of trust.

For School Personnel Only
Proof of residency verified                          Change entered in PWS

                   initials
                   date
                   document seen

                    initials
                    date