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Annual Filing

Private School Affidavit Form

Thank you for submitting your Private School Affidavit online. This is your Private School Affidavit Certification. Please print this page, and maintain a hardcopy for a period of three years. Do NOT mail a copy to the California Department of Education.

Form Submitted: 12/11/2017 7:31:22 PM
Confirmation: 232684
Page Generated: 4/25/2019 8:56:55 PM

From Education Code Section 48222: This is "... a private[that]...offer[s] instruction in the several branches of study required to be taught in public schools of the state,...[that offers this] English [, and that keeps]...attendance [records]..." * Yes

School Information

1. Name of School C.Theology Uni
2. CDE-assigned 14 digit CDS code if one was previously assigned 19647336155089
3. County in which school is located Los Angeles
4. Public school district in which school is located Los Angeles Unified
5. Street Address (P.O. Box is not acceptable 6556 Fountain Avenue Los Angeles 90028
6. City Los Angeles, CA  90028 -
7. School Telephone Number 213-447-3546
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 (only if different from #5 above)
13. Mailing City (only if #12 has response)    -
14. Type of School Coeducational
15. School Accommodations Day Only
16. Does the school provide special education services? No
17. Grade Span offered Lowest: 6    Highest: 12
18. High School Diploma Offered No
19. Classification of school Religious (Code:ISLM)

Prior Year School Information

20. Has this school ever filed a Private School Affidavit under a different school name? No
21. Former name of school (if "Yes" answered to previous question)
22. Has the public school district changed since filing last year's PSA? 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: 10 years, 0 months
Oldest: 12
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
Eighth Grade 0
Ninth Grade 0
Tenth Grade 2
Eleventh Grade 0
Twelfth Grade 5
Ungraded Elementary 0
Ungraded Secondary 0
Total Enrollment 7
26. Number of Twelfth Grade Graduates in 2016-2017 School Year 4
27. Number of School Staff
Staff Type Number of Staff
Full-time Teachers 1
Part-time Teachers 0
Administrators 0
Other Staff 0
"Other Staff" includes instructional aides, therapists, secretaries, etc.

Administrative Staff

28. Site Administrator Mr. Ismail Yetis
29. Site Administrator Title Administrator
30. Site Administrator E-mail Address
31. Director or Principal Officer Name Mr. Ismail Yetis
32. Director or Principal Officer Position Administrator
33. Director or Principal Officer Address 6554 Fountain Avenue Los Angeles 90028
34. Director or Principal Officer City Los Angeles, ca   90028 -
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 Mr. Salih Yetis
37. Address (Location of Records) 6554 Fountain Avenue Los Angeles 90028
38. City Los Angeles, ca   90028 -
39. E-mail Address

Tax Status of School

40. Tax-exempt, nonprofit status under Section 501(c)(3) of the 1954 U.S. Internal Revenue Code - NO

41. Tax-exempt, nonprofit status under Section 23701d of the California Revenue and Taxation Code - NO

42. Property tax exemption under Section 214 of the California Revenue and Taxation Code - NO

43. None of the above - YES

Acknowledgements and Statutory Notices

"YES" indicates your understanding of the statement and your school's compliance.

44.YES All Private School Affidavits are public documents viewable by the public.
45.YES 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.YES 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.YES The Affidavit is not a license or authorization to operate a private school.
48.YES 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.YES 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.YES 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.YES Retain a copy of this document for a period of three years.
52.YES 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.YES 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.YES 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 Ismail Yetis
Title Mr.
Telephone Number 213-447-3546
Electronic Signature - Birth Month ***** Not displayed for security purposes
Electronic Signature - Birthday ***** Not displayed for security purposes
Electronic Signature - Question What is your favorite sport?
Electronic Signature - Answer ***** Not displayed for security purposes

Form Submitted: 12/11/2017 7:31:22 PM
Confirmation: 232684
Page Generated: 4/25/2019 8:56:55 PM

California Department of Education
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Sacramento, CA 95814

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