Annual Filing

Private School Affidavit Form
2016-17

(covers the period October 1, 2016 through September 30, 2017)

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.

Please 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]..." *	A Private School Affidavit cannot be filed if the answer to this question is NO.

School Information

1. Name of School *
2. Enter your CDE-assigned 14 digit CDS code if one was previously assigned
3. County in which school is located *
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) *	Examples: 5432 West Oak Street, Suite 12 853 Park Street 286 Avenue 14, Building A
6. City *	State * Zip * -
7. School Telephone Number *	( ) -
8. Optional School Fax Number	( ) -
9. School E-mail Address *
10. Optional School E-mail Address
11. Optional School Web Site Address
12. Mailing Address (required *, only if different from #5 above)
13. Mailing City (required *, only if #12 has response)	State Zip -
14. Type of School *	Coeducational Boys Only Girls Only
15. School Accommodations *	Residential Boarding Only Day Only Both
16. Does the school provide special education services?	Yes No
17. Grade Span offered *	Lowest: Highest:
18. High school diploma offered	Yes No
19. Classification of school	Non-Religious Religious - Select from list:

Prior Year School Information

20. Has this school ever filed a Private School Affidavit under a different school name? *	Yes No
21. Enter former name of school (if "Yes" answered to previous question)
22. Has the public school district changed since filing last year's PSA? *	Yes No
23. Former public school district (if "Yes" answered to previous question)

Statistical Information

24. Range of students' ages *
(Youngest may be no younger than 4 years and 9 months)

Youngest: Years, Months
Oldest: Years

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
First Grade
Second Grade
Third Grade
Fourth Grade
Fifth Grade
Sixth Grade
Seventh Grade
Eighth Grade
Ninth Grade
Tenth Grade
Eleventh Grade
Twelfth Grade
Ungraded Elementary
Ungraded Secondary
Total Enrollment

26. Number of twelfth grade graduates in 2015-2016 school year *

27. Number of school staff *

Staff Type	Number of Staff
Full-time Teachers
Part-time Teachers
Administrators
Other Staff

"Other Staff" includes instructional aides, therapists, secretaries, etc.

Administrative Staff

28. Site Administrator *	First: * Last: *
29. Site Administrator Title *
30. Site Administrator E-mail Address *
31. Director or Principal Officer Name *	First: * Last: *
32. Director or Principal Officer Position *
33. Director or Principal Officer Address *
34. Director or Principal Officer City *	State * Zip * -
35. Director or Principal Officer E-mail Address

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 *	First: * Last: *
37. Custodian of Records Address *
38. Custodian of Records City *	State * Zip * -
39. Custodian of Records E-mail Address

Tax Status of School *

40.Tax-exempt, nonprofit status under 501(c)(3) of the U.S. Internal Revenue Code
41.Tax-exempt, nonprofit status under Section 23701d of the California Revenue and Taxation Code
42.Property tax exemption under Section 214 of the California Revenue and Taxation Code
43.None of the above

Acknowledgements and Statutory Notices *

Each box is required. Checking a box indicates your understanding of the statement and your school's compliance.

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 *
Title *
Telephone Number *	( ) - ext
Electronic Signature - Birth Month *
Electronic Signature - Birthday *
Electronic Signature - Question *
Electronic Signature - Answer *

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 2016-17 Private School Affidavit with Confirmation Number.

Questions: Private Schools Office

California Department of Education
1430 N Street
Sacramento, CA 95814

Web Policy

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.

Annual FilingPrivate School Affidavit Form 2016-17