Appendix III, Chart III

Affidavit

State of Texas ___________________ §

County of _______________________ §

Before me, the undersigned Notary Public, on this day personally appeared _______________________________________ , known to me, who being by me duly sworn upon his/her oath, deposed and said:

1. My name is ___________________________. I am _______ years of age and have personal knowledge of the facts stated herein and they are all true and correct.

2. I graduated or will graduate from a Texas high school or received my GED certificate in Texas.

3. I resided in Texas for three years leading up to graduation from high school or receiving my GED certificate.

4. I have resided or will have resided in Texas for the 12 months prior to the census date of the semester in which I will enroll in ___________________________________ (college/university).

5. I have filed or will file an application to become a permanent resident at the earliest opportunity that I am eligible to do so.

In witness whereof, this __________ day of _________________, _______________ .

_______________________________________
(Signature)

_______________________________________
(Printed Name)

_______________________________________
(Student I.D. #)

SUBSCRIBED TO AND SWORN TO BEFORE ME, on the _______________ day of ______________________, ________- , to certify which witness my hand and official seal.

______________________________________
Notary Public in and for the State of Texas