STUDENT ROSTER Teacher’s Name: ___________________________________ (List each student that is receiving services from this teacher) Student’s Name MSIS/SSN Date of Birth Grade Level Mississippi Resident (Legal Name as (List the MSIS or (List the student’s Verification (Enter the registered in Social Security current grade code from the chart school) Number) level) below) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Residency Verification Legend Note: 504 Teacher Units are allocated for Code Residency Verification A Filed Homestead Exemption educational services to children who are B Mortgage Documents/Property Deed eligible for services under Section 504 and C Apartment or home lease who are NOT Eligible for special education as D Utility Bills defined under Part B of the Individuals with E Valid Driver’s License Disabilities Education Act and in State F Automobile registration regulations. G Voter precinct identification H Affidavit of designated school district official I Certified copy of guardianship petition
STUDENT ROSTER Teacher’s Name: ___________________________________ (List each student that is receiving services from this teacher) Student’s Name (Legal Name as registered in school) MSIS/SSN (List the MSIS or Social Security Number) Date of Birth Grade Level (List the student’s current grade level) Mississippi Resident Verification (Enter the code from the chart below) 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. Residency Verification Legend Code Residency Verification A Filed Homestead Exemption B Mortgage Documents/Property Deed C Apartment or home lease D Utility Bills E Valid Driver’s License F Automobile registration G Voter precinct identification H Affidavit of designated school district official I Certified copy of guardianship petition Note: 504 Teacher Units are allocated for educational services to children who are eligible for services under Section 504 and who are NOT Eligible for special education as defined under Part B of the Individuals with Disabilities Education Act and in State regulations.
Student%20Roster_20180717091231_569440.docx