Mary Jane Burke

Marin County Superintendent of Schools Business Services Department Business Bulletin 18-09

Average Daily Attendance Credit during Emergencies October 13, 2017

All Marin County public schools were closed on October 13, 2017 as a result of staffing impacts from the regional wildfires. The attached press releases from Mary Jane Burke, Marin County Superintendent of Schools and State Superintendent of Public Instruction (SSPI) Tom Torlakson, and the newspaper article from the Marin Independent Journal published Friday October 13, 2017 provide you with the necessary supporting documentation to make a claim for attendance credit during this emergency closure. Districts that experience low student attendance at any time during this period may be able to claim a material decrease in average daily attendance (ADA) for any day attendance falls by 10% or more due to the regional wildfires. Requests for ADA credit for school closures and/or a material decrease in ADA can be made by completing the attached Form J- 13A (Request for Allowance of Attendance Because of Emergency Conditions). The original form (with the board members' affidavit) and two copies should be filed with the county superintendent of schools. The approved request for credit ensures a District does not suffer a loss of attendance and the associated funding as well as providing credit for instructional days and minutes. Please forward the original documents to the Business Services Department of the Marin County Office of Education to the attention of Penny Stevenson. Upon the county superintendent's approval of the request, the county superintendent will execute the affidavit certifying the approval and we will forward all pages of the original and one copy of the form to the California Department of Education (CDE), School Fiscal Services Division. For charter schools, requests submitted require the signature of the superintendent of their authorizing local educational agency (LEA), in addition to the affidavits of the charter school governing board members and the county superintendent of schools (J-13A, page 5C). For detailed information and instructions for claiming ADA credit during periods of emergency, please refer to the attached CDE Management Advisory 90- 01 revised on February 10, 2005. Please report any insurance claims to Keenan & Associates for damages that occurred. If you have any questions, please call or email Penny Stevenson at (415) 499-5832 / pstevenson@marinschools.org or Kate Lane at (415) 499 5822 / klane@marinschools.org.

FOR IMMEDIATE RELEASE CONTACT: Mary Jane Burke October 12, 2017 Marin County

Superintendent of Schools (415) 499-5801

Marin County Public Schools Close Due to Staffing Impact from Regional Wildfires

Marin County school districts have decided to close schools on Friday, October 13 as a result of a variety of challenges related to the wildfires regionally. More than 1,000 Marin school employees live in the northern counties affected by the wild fires. We know that our community resources are being stretched including the ability of staff to report to work as well as the emotional stress on people impacted by the fires directly or indirectly. "We have been in close contact with our districts and have considered a variety of options in the best interest of our students and staff," said Mary Jane Burke, Marin County Superintendent of Schools, "We think it is very important that the school districts countywide provide a consistent message and we feel that we need to support our staff, families and community as a whole. Our hearts go out to the families who are facing these devastating circumstances." School related sports activities countywide have been canceled through the weekend as a result of poor air quality. Advice from the Marin County Public Health Officer is for people to remain indoors with limited physical exertion. Several school sites throughout the county have been identified and are prepared to serve as evacuation shelters tomorrow and potentially into the future if needed. The College of Marin and Dominican University of California will also be closed on Friday. Schools will plan to return to normal operations on Monday.

Home / Newsroom / News Releases / Year 2017

Release: #17-75October 12, 2017

Contact: Robert OakesE-mail: communications@cde.ca.govPhone: 916-319-0818

State Schools Chief Tom Torlakson Assures Schools Closed by Hazardous Air Quality that State Funding

Will Continue SACRAMENTO— State law allows schools to apply to receive state Average Daily Attendance (ADA) funding, the main source of school funding, if they have to close because of a natural disaster such as floods, fires, or earthquakes.

State Superintendent of Public Instruction Tom Torlakson today announced that schools closed because of dangerous air quality can also apply to receive state Average Daily Attendance (ADA) funding, and that they will be assisted by administrators from the California Department of Education (CDE).

Nearly 600 schools with about 260,000 students statewide are closed today because of fire danger, dangerous air quality, and evacuations.

"I want to thank these school districts for taking swift and decisive action to protect educators and students, and to let them know that the California Department of Education will assist them in any way that we can,” he said. “Safety must come first for students, teachers, and staff.”

The CDE Nutrition Services Division on Tuesday sent two truckloads of frozen food and dry goods to the Redwood Empire Food Bank in Santa Rosa to assist fire victims and has offered to send more food. Torlakson also said that students who are homeless because of fire damage can be immediately enrolled in schools even if they do not have the necessary paperwork to enroll, such as proof of residency. Information is available from the National Center for Homeless Education .

Page 1 of 2Funding Continues for Schools Closed by Unsafe Air - Year 2017 (CA Dept of Education)

10/13/2017https://www.cde.ca.gov/nr/ne/yr17/yr17rel75.asp

A list of school closures is available by contacting communications@cde.ca.gov and will be listed on the CDE Web site. Torlakson also encouraged schools facing poor air quality to keep students indoors during recess and meals. Air quality and fire information is available from the California Office of Emergency Services .

The California Department of Education (CDE) this morning had tracked school closures in Amador, Butte, Calaveras, Colusa, Contra Costa, El Dorado, Lake, Mendocino, Napa, Orange, Solano, Sonoma, Sutter, and Yuba counties.

Approval of school closures related to dangerous air quality can be requested by submitting three copies of Form J-13A (DOC). For more guidance on ADA relief, see the CDE’s Management Advisory 90-01 on ADA credit during periods of emergency.

# # # #

Tom Torlakson — State Superintendent of Public InstructionCommunications Division, Room 5602, 916-319-0818, Fax 916-319-0100

Last Reviewed: Thursday, October 12, 2017

Page 2 of 2Funding Continues for Schools Closed by Unsafe Air - Year 2017 (CA Dept of Education)

10/13/2017https://www.cde.ca.gov/nr/ne/yr17/yr17rel75.asp

-- -- - -

~ atin dlnbtptnbtnt J_outnal Friday, October 13, 2017 MARIN I

-SCHOOLS CLOSED I

IN FIRE FALLOUT ·.

Pg. 1 _ _ 1 ERIC RISBERG - THE ASSOCI ATED PRESS

Smoke and haze from wildfires _hovers ov~ r t h.e skyline Thursday in San Fra ncisco. The poor air quality has forced cance llation of school- I

Closures: Many teachers, staff live in areas affected By Mark Prado mprado@marinij.com @MarkPradoIJ on Twitter

All Marin public schools have canceled class Friday be­cause of the ongoing wildfires and the residual effect on staff­ing, officials announced Thurs­day afternoon.

Meanwhile, Marin contin­ues to suffer from an invasion of smoke from the fires. San Rafael had the second worst air quality in the entire coun­try at one point Thursday, only behind Houston, according to the U.S. Environmental Protec­t ion Agency.

The decision to close schools had more to do with logistics than air quality. More than 1,000 Marin school employees live in the northern counties

affected by the wildfires. "We have been in close con­

tact with our districts and have considered a variety of options in the best interest of our stu­dents and staff," said Mary Jane Burke, Marin County su­perintendent of schools, in a statement. "We think it is very important th~t the school dis­tricts countywide provide a consistent mc:;sage and we feel that we need to support our staff, families and com­munity as a whole."

School-related sports activi­ties countywide also have been canceled through the weekend as a result of poor air quality.

Several school sites through­out the county have been iden­tified and are prepared to serve as evacuation shelters Friday

SCHOOLS »PAGE 7

Pg. 2

Pg. 3

Schools FROMPAGEl

and potentially into the fu­ture if needed, according to school officials.

The College of Marin, Do­minican University of Cal­ifornia and San Francisco State University - includ­ing its Romberg Center for Environmental Studies in Tiburon - also will be closed on Friday. Schools are planning to return to normal operations on Mon­day.

San Rafael's logging of the second worst air qual­ity in the nation was noted at 1 p.m. as a orange-yel­low haze descended on the county. San Rafae1 is the only location in the county with an air monitor. The city remained in the top five poor air quality locales for much of the day.

The air quality index reading in San Rafael regis­tered at 164 at the EPA web­site airnow.gov. That put San Rafael's air in the "un­healthy" category. A healthy reading is less than 100. The reading reflects a mea­sure of the particulate mat­ter or soot in the air. At the same time San Francisco had a 162 reading, Fairfield, 161 and Napa, 160. Houston had a 209. The air quality index is an EPA color-coded ,ool for communicating air quality to the public. That EPA website was so busy be­cause of all the fires, it was often slow to load.

A Bay Area Air Qual­ity Management District's health advisory and "Spare the Air" continue to be in place through the weekend due to the fires.

Meanwhile, a "red flag warning" issued by the National Weather Ser­vice wound down at 5 p.m. Thursday, and feared in­tense winds didn't mate­rialized. Another round of strong and gusty offshore winds is expected in the hills Friday night into Sat­urday morning, according to the weather service.

Six strike teams from Marin, with five fire en­gines each, have been de-

MARINIJ.COM I NEWS-0 1 7

MAJOR WINE COUNTRY FIRES -1:- -- -~

~1c1overdale , "\.., ,, . .. 9 ' (, ( 175

",) '" , \

Approximate burn areas '\':~

\ '\\ ·"~~serville

\ 1! '\ \ ).\_.~--

SONOMA COUNTY

Evacuation areas

As of 7 p.m. Thursday

' \ ' Lilk!I \ " \

, Ber,.Ye~a '\ ; ·~

"

Pocket fire: 8.430 acres U Atlas fire: 43,762 acres, Tubbs fire: 34.770 acres. 3% contained 10% contained «!) Partrick fire: 10,817 acres.

C)Adobe fire: 7,955 acres. 2% containment 1 % contained 41) 37 fire: 1,660 acres,

0 Pressley fire: 473 acres, 90% contained 1% containment

(l) Nuns and Norrbom fires (combined): 14,698 acres. 3% contained

Sources: Cal Fire: News reports

ployed to assist with the North Bay wildfires, but the county is well staffed, offi­cials say.

Novat o police Chief Adam McGill and Fire Chief Mark Heine sent out an alert to residents to ease fears of fire danger.

"Both departments re ­main fully staffed in No­vato and under normal operations ," the joint statement read. "We are prepared to respond to any emergencies in No­vato. While we do not an­ticipate any need for evac­uations in Novato, we are contilluing to work closely with City staff to actively monitor the fire activ­ity in Sonoma and Napa Counties and any poten­tial threats to Novato."

The Marin County Of­fice of Emergency Services and Department of Health and Human Services con­tinue to operate a shelter for evacuees at Marin Cen-

In Mendocino County (Not on map) Redwood/Potter fires: 32,100 acres, 5% contained Sulphur fire: 2,500 acres, 45% contained

BAY AREA NEWS GROUP

ter Exhibit Hall. Wednesday night, the center housed 487 people. Other sponta­neous shelters across the county, including in Novato and West Marin, housed an additional 191 evacuees, the county reports. Workers are trying to make the sites as homey as possible and a children's sing along music class was set for Thursday afternoon at the Civic Cen­ter shelter.

California State Parks announced it is opening the Bodega Dunes Camp­ground and Wrights Beach within Sonoma Coast State Park and Woodside Camp­ground within Salt Point State Park for evacuees. Services available at these sites include showers, bath­rooms, drinking water and trash bins.

There is the cent ral­ized hub for all verified campaigns for those im­pacted by the fires : www. gofundme.com/CAfirerelief.

California Department of Education (http://www.cde.ca.gov/fg/sf/aa/ma9001.asp)Page Generated: 12/11/2014 11:58:49 AM

February 22, 1990 (revised February 10, 2005)

Dear District and County Superintendents, District and County Business Officers, and District and County Attendance Officers:

MANAGEMENT ADVISORY 90-01

AVERAGE DAILY ATTENDANCE CREDIT DURING PERIODS OF EMERGENCY

This advisory provides instructions on how to claim average daily attendance (ADA) and instructional time credit for days on which schools are forced to close, or days when schools are open but attendance is reduced, because of emergency conditions.

Two sections of the Education Code allow the State Superintendent of Public Instruction (SSPI) to grant normal apportionment credit to districts in emergencies. Education Code Section 41422 authorizes maintenance of apportionments in instances when one or more schools must be closed because of "extraordinary conditions." When the SSPI authorizes credit for days that school was closed, districts receive ADA credit for all purposes and instructional time credit for the day(s) and minutes lost to the emergency closure. The instructional time credit satisfies state law with regard to both the 175-day minimum year and "longer day and year" requirements.

Section 46392 of the Education Code provides for the crediting of ADA "whenever the average daily attendance of any school district, county office of education, or regional occupational center or program...has been materially decreased...because of fire...flood...impassable roads [and other specified circumstances]." Although the wording of the two code sections differs in detail, the effect is the same. School districts and county offices are to be held harmless from revenue loss that might otherwise result from the loss of ADA or instructional time in emergencies.

School Closures

Most emergencies do not require that schools be closed for more than a few days, and it is of course desirable to reopen school and return to normal instructional activities as soon as safe operations can be assured. If any school will have to be closed for an extended period of time, districts should make alternative arrangements for students in other facilities.

To prevent school closure from reducing ADA, districts should deduct approved emergency days from the days in the reporting period divisor when calculating the ADA of the school that was closed. In this manner the days on which the school was closed will not reduce the average attendance quotient, although the emergency days will be credited towards the requirements to maintain school for 175 or 180 days. The regularly scheduled minutes of instruction for those days are counted toward the annual minutes requirement for the "longer day and year." If different schools are closed for different days, then ADA should be calculated on a school-by-school basis (using the appropriate divisor for each school); the ADA of all schools should then be summed to obtain a district total that will be reported to the state. Districts should obtain approval of their days of emergency closure (and thus permission to reduce the reporting period days) by submitting a Form J-13A as described later in this advisory. The approved J-13A forms, combined with other district records, serve to document the district's compliance with instructional time laws (including "longer day and year" requirements) as well as show why different divisors may be used in the computation of ADA for different schools.

Material Decrease and Credit Calculations

Districts that keep schools open during, or immediately after, an emergency may find that attendance is below normal. If the attendance of a school or program is less than 90 percent of "normal" for a reasonable time after the event, then the district may assume that a case exists for claiming emergency attendance credit for the "material decrease" of ADA. Any reduction of ADA in a necessary small school, even if less than 10 percent, may be considered material.

Title 5, California Code of Regulations, Section 428 (amended effective December, 1989) provides that "the average daily attendance of the school during either the [school] month of May or the month of October of the same school year shall be used to determine the normal attendance of a school for purposes of calculating material decrease credit." (If those options do not appear reasonable under particular conditions, the Superintendent retains broad authority under Section 41422 to approve other

Page 1 of 3Management Advisory 90-01 - Attendance (CA Dept of Education)

12/11/2014http://www.cde.ca.gov/fg/sf/aa/ma9001.asp?print=yes

requested methods of calculating normal attendance.)

The resultant "normal" ADA figure will also be used as the material decrease credit. For example, a district choosing to use its May ADA of say, 388 would be credited with 388 days of student attendance for each day during which there was a material decrease (that is, creditable attendance of less than 349 [90 percent of 388]).

Credit Approval

School closure or ADA credit for material decrease cannot be approved unless the reason for closure of loss of attendance can reasonably be related to an emergency situation. Once schools are reopened, normal attendance should return within a few days; the district should claim material decrease credit only for the days immediately following the emergency. When approval of school closure or material decrease credit is requested via the J-13A form, the district should explain the extraordinary conditions that prevented normal operations or kept students from returning to class.

Attendance credit and approval of school closures may be obtained by submitting three copies of Form J-13A (Request for Allowance of Attendance Because of Emergency Conditions) to your county office of education (county offices should file their own J-13As directly with the state). The J-13A form replaces the J-13 form that was used previously. A fourth copy of the form should be retained by the requesting district or county. Since only one copy of the J-13A is attached, it should be used as a master to make multiple copies for filing. Form J-13A may also be used to make claims for attendance when attendance records have been lost or destroyed. Approval requires the affidavits of the district governing board members and the county superintendent of schools (J-13A, page 5). Requests submitted for charter schools require the signature of the superintendent of their authorizing local educational agency (LEA), in addition to the affidavits of the charter school governing board members and the county superintendent of schools (J-13A, page 5C). After the county superintendent of schools has verified the supporting information and approved the request, the forms should be forwarded to:

School Fiscal Services DivisionCalifornia Department of Education

1430 N Street, Suite 3800Sacramento, CA 95814

Districts and their county offices will be notified when requests for school closure or attendance credit are approved.

Locally maintained attendance records, including teacher registers, should be marked "Emergency Closure" on days when school has to be closed for emergency conditions. Attendance should be recorded as usual on days that may later be determined to be days of material decrease. Upon approval of a request for relief of a material decrease, the credited days of student attendance will be substituted for actual (decreased) days when computing ADA for reporting on the School District Attendance data entry screen in the Principal Apportionment Revenue Limit software. Actual attendance records should not be changed for days of material decrease, since these records will be needed to substantiate that a material decrease did occur. Since all attendance records are subject to audit, districts and counties should be careful to retain all supporting records and documents for later review.

Child Development Programs

Child care, child development, and preschool programs are not funded through average daily attendance, but similar allowances exist for the granting of emergency day credit. For further information, contact your assigned consultant in the Department's Child Development Division, or call Greg Hudson at 916-323-1300.

Application of Law and Policy to Other Events

The emergency day and material decrease credits that are described in this advisory have been available to districts for many years, although claiming details and policies have changed somewhat over time. In recent years, attendance credit has been granted to districts affected by floods, fires, earthquakes, and various isolated instances of heavy snow, fog-closed roads, and other emergencies.

In past years, the emergency attendance credits were guided by regulations that required the "make-up" of lost time under certain conditions and required various ADA loss calculations to determine if an ADA loss was sufficiently "material." These regulations have been replaced by simpler guidelines that are reflected in this advisory. The elimination of requirements to "make-up" instructional time losses should not be misconstrued. In an emergency, the health and safety of students and staff are the primary concern, but the instructional program should not be allowed to be a secondary casualty. Although no longer required to do so, districts and county offices should make every effort to replace instructional time losses and restore the instructional program as soon as safety allows.

Emergency ADA credit is obviously not intended to be used when the conditions that cause school closure could have been foreseen or avoided. In locales where normal winter snow or fog will predictably force school closure for a few days every year, districts are expected to foresee the need to close and schedule "extra" days in the school calendar in order to compensate for the foreseeable loss of instructional time. Emergency ADA credit will not be granted to districts that attempt to abuse the allowance to compensate for foreseeable circumstances; however, credit may be requested (as usual) when adverse weather conditions, which could not be reasonably predicted, cause school closure or material decrease. Credit may also be granted to districts that expect and make provision for a few days of weather closure but experience more than expected problems. What is "reasonable" for any given district will vary, of course, but the actual experience of the district over the last five fiscal years should establish a case for the number of days that school may reasonably be expected to be closed for fog, snow, or other weather problems.

Page 2 of 3Management Advisory 90-01 - Attendance (CA Dept of Education)

12/11/2014http://www.cde.ca.gov/fg/sf/aa/ma9001.asp?print=yes

Last Reviewed: Tuesday, May 27, 2014

For further information or assistance in completing the J-13A, please contact Carina Saraiva-Perez, Analyst, School Fiscal Services Division, at (916) 322-6068 [Note, the preceding contact name and phone number are no longer valid and have been replaced by Office of Principal Apportionment and Special Education, at 916-324-4541 or by e-mail at PASE@cde.ca.gov.]

To the extent that this Management Advisory contains guidelines in addition to recitation of the law, the guidelines are exemplary only, and compliance with them is not mandatory.

Page 3 of 3Management Advisory 90-01 - Attendance (CA Dept of Education)

12/11/2014http://www.cde.ca.gov/fg/sf/aa/ma9001.asp?print=yes

California Department of Education Form J-13A

REQUEST FOR ALLOWANCE OF ATTENDANCE BECAUSE OF EMERGENCY CONDITIONS

Form J-13A (Rev. 01-05) School District (or Charter School) Name:

School District (or Charter School) Address:

County-District Code:

County Name: This form replaces the Form J-13A (Rev. 4-90) and should be used to obtain approval of attendance and instructional time credit under one or more of the following conditions:

• When one or more schools were closed because of conditions described in Education Code Section 41422

• When one or more schools were kept open but experienced a material decrease

in attendance because of conditions described in Education Code Section 46392

• When attendance records have been lost or destroyed as described in Education Code Section 46391

Approved credit for instructional time may be used in conjunction with regular instructional days to satisfy the requirements of Education Code Section 37202 (equal length of instructional time among schools within a district). A separate form should be submitted for each emergency event, but credit may be requested for more than one school and under one or more of the foregoing conditions on the same form. Each separate form must include the affidavit of the governing board members and the county superintendent before it can be approved by the State Superintendent of Public Instruction. The original form (with the board members' affidavit) and two copies should be filed with the county superintendent of schools. If the county superintendent approves the request, he or she should execute the affidavit certifying that approval and forward all pages of the original and one copy of the form to:

Office of Principal Apportionment and Special Education School Fiscal Services Division California Department of Education 1430 N Street, Suite 3800 Sacramento, CA 95814

This form consists of five preprinted pages. Pages 1 and 5 (5C for charter schools) must accompany all submissions. Page 4 (Lost or Destroyed Attendance Records) will not need to be submitted by most districts. Multiple copies of Pages 2 and/or 3 may have to be submitted when claims are made on a school-by-school basis.

Page 1

California Department of Education Form J-13A

SCHOOL CLOSURE Nature of Emergency (describe): Name of School(s): (if request covers all schools, write "all schools") School Code(s): We request that apportionments be maintained and instructional time credited for the above named school(s) without regard to the fact that the school(s) were closed on (dates): because of the described emergency. Approval of this request authorizes the local educational agency to disregard these days in the computation of average daily attendance (ADA) (per Section 41422) and obtain credit for instructional time for the days and the instructional minutes that would have been regularly offered on those days pursuant to Education Code Section 46200, et seq. If the school closure resulted from a power outage or impassable roads caused by inclement weather, state the number of school closure days for the same conditions in each of the last five years:

Page 2

California Department of Education Form J-13A

MATERIAL DECREASE Nature of Emergency (describe): Name of School: (if request covers all schools, write "all schools") School Code(s): We request the substitution of estimated days of attendance for actual days of attendance in accordance with the provisions of Section 46392. Approval of this request will authorize use of the estimated days of attendance in the computation of apportionments for the foregoing school(s) for (dates) during which school attendance was materially decreased because of the described emergency. Estimated attendance for each day (October or May ADA): students per day. Estimated daily attendance multiplied by number of days of material decrease, yields days of attendance requested. State method of determining estimated daily attendance (October or May ADA):

ADA for school month beginning on , 2 and ending on , 2 . Actual apportionable attendance for days of material decrease: Site Date Actual Attendance

Page 3

California Department of Education Form J-13A

LOST OR DESTROYED ATTENDANCE RECORDS

We request the use of estimated attendance in lieu of attendance that cannot be verified because of the loss or destruction of attendance records. This request is made in accordance with Section 46391. The entire period covered by the lost or destroyed records commences with , 2 , up to and including, , 2 . Describe circumstances and extent of records loss or destruction: Describe how it is proposed to reconstruct attendance records or estimate attendance in the absence of records:

Page 4

California Department of Education Form J-13A

AFFIDAVIT OF GOVERNING BOARD MEMBERS

We, members constituting a majority of the governing board of the school district, hereby swear (or affirm) that the foregoing statements are true and are based on official district records.

Printed Names

Signatures

At least a majority of the members of the governing board shall execute this affidavit. Subscribed and sworn (or affirmed) before me, this day of , 2 .

Signature, Title

of County, California Contact/Individual responsible for preparing this form:

Name: Title:

Phone: Fax : E-mail:

AFFIDAVIT OF COUNTY SUPERINTENDENT OF SCHOOLS

The information and statements contained in the foregoing request are true and correct to the best of my knowledge and belief. Signature, County Superintendent of Schools

Date: Subscribed and sworn (or affirmed) before me, this day of , 2 .

Signature, Title

of County, California Contact/Individual responsible for preparing this form:

Name: Title:

Phone: Fax : E-mail:

Page 5

California Department of Education Form J-13A

AFFIDAVIT OF CHARTER SCHOOL GOVERNING BOARD MEMBERS

We, members constituting a majority of the governing board of the charter school, hereby swear (or affirm) that the foregoing statements are true and are based on official district records.

Printed Names Signatures

At least a majority of the members of the governing board shall execute this affidavit. Subscribed and sworn (or affirmed) before me, this day of , 2 .

Signature, Title

of County, California Contact/Individual responsible for preparing this form:

Name: Title:

Phone: Fax : E-mail:

Approval by Superintendent of Authorized Local Educational Agency (LEA) Signature, Title

of (LEA).

AFFIDAVIT OF COUNTY SUPERINTENDENT OF SCHOOLS

The information and statements contained in the foregoing request are true and correct to the best of my knowledge and belief. Signature, County Superintendent of Schools Date: Subscribed and sworn (or affirmed) before me, this day of , 2 .

Signature, Title

of County, California Contact/Individual responsible for preparing this form:

Name: Title:

Phone: Fax : E-mail:

Page 5C