Governor Mifflin School District

Act 153 Volunteer Affidavit

I attest to the following statements in lieu of obtaining the FBI clearance as allowed by Act 153 of 2014 for volunteers:

  1. I am applying for the position of _____________________________________, an unpaid, volunteer position with the Governor Mifflin School District.
  2. I have been a resident of the Commonwealth of Pennsylvania for the entirety of the ten (10) year period immediately preceding the date of this Affidavit.
  3. I am not disqualified from service as a volunteer as a result of a conviction of one or more of the following offenses listed under Title 18 of the Pennsylvania Crimes Code, or the attempt, solicitation or conspiracy to commit any of the following offenses:                                                                                         


4. I have not been convicted of an offense similar in nature to those offenses listed in Paragraph 3 herein under the laws or former laws of the United States or one of its territories or possessions, another state, the District of Columbia, the Commonwealth of Puerto Rico or a foreign nation, or under a former law of this Commonwealth.


I hereby affirm that the information in this affidavit is true and correct to the best of my knowledge and belief and that the signature is being made subject to 18 Pa.C.S.A. § 4903 relating to crimes for false sworn statements which is a misdemeanor of the third degree punishable by up to one year imprisonment.

__________________  _______________________________  _________________________

        Date                        Affiant Printed Name                           Affiant Signature        

__________________  _______________________________  _________________________

        Date                        Witness Printed Name                    Witness Signature