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Annual Filing

Private School Affidavit Form
2014-15

(covers the period October 1, 2014 through September 30, 2015)

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.

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

School Information

Use the district name lookup tool to enter information into the box.

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 and ask for the "district locator."

Examples:
5432 West Oak Street, Suite 12
853 Park Street
286 Avenue 14, Building A
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14. Type of School *


15. School Accommodations *

16. Does the school provide special education services?   
Lowest:
18. High school diploma offered   
19. Classification of school
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Prior Year School Information

20. Has this school ever filed a Private School Affidavit under a different school name? *
22. Has this school changed public school districts? *

Statistical Information

24. Range of students' ages *
(Youngest may be no younger than 4 years and 9 months)
Years,
Years
25. Enrollment on a single date between October 1-15, 2014. If school was not operating during this period, enter enrollment on a single date during current month. *

(NOTE: Do not report pre-school enrollment; pre-schools that do not offer kindergarten should not file this PSA.)

Grade Number of Pupils
27. Number of school staff *
Staff Type Number of Staff
"Other Staff" includes instructional aides, therapists, secretaries, etc.

Administrative Staff

     
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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.

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Tax Status of School *

40.
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43.

Acknowledgements and Statutory Notices *

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

44.
45.
46.
47.
48.
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51.
52.
53.
54.

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.

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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 2014-15 Private School Affidavit with Confirmation Number.

Questions: Private Schools Office

California Department of Education
1430 N Street
Sacramento, CA 95814

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