"Domiciliary Reclassification Application Form - Tidewater Community College" - Virginia

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SS-031
Domiciliary Reclassification Application Form
DOMICILE AFFIDAVIT To become eligible for in-state tuition, a student shall establish by clear and convincing evidence that for a period of at least one year im-
mediately prior to the first day of classes, he or she was domiciled in Virginia and has abandoned any previous domicile, or that the person on whom the student is
legally and financially dependent was domiciled in Virginia. This form must be completed if you are claiming entitlement to Virginia in-state tuition rates pursuant
to section 23.7-4, code of Virginia. All questions must be answered. Where not applicable answer N/A.
SECTION A: APPLICANT
SIS ID ________________________________
1.
Name of Applicant: __________________________________________________________________Birthday ______/______/_______
Last
First
Middle
Month
Day
Year
2.
Are you a U.S. Citizen? ____Yes ____No If “No,” are you a permanent resident? ____Yes ____No
If “Yes,” what is your “A number?” ________________________ If “No,” what is your immigration status? ____________________________
3.
How long have you lived in Virginia? _____________ years, ______________ months
4.
Where have you lived the last two years? List current address first:
From (mm/yr) To (mm/yr) Street Address
City
State
Zip
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
5.
q Yes q No Do your parents/legal guardian provide over half of your financial support or claim you as a tax dependent?
If no, go to #6. If yes, sign section E and have your parent/ legal guardian complete sections D & E
6.
q Yes q No
Do you wish to claim in-state tuition rates based on your Virginia domiciliary residency status?
If no, where will you retain legal domicile ?___________________________________________________________________
State
Country
If yes, continue to SECTION B. If no, go to #7
7.
q Yes q No Do you wish to claim in-state tuition based on your spouse’s domiciliary status?
If no, sign SECTION E. If yes, sign Section E & have your SPOUSE complete sections D & E
SECTION B: STUDENT STATUS
1.
q Yes q No
Will you be age 24 or older before the first day of classes?
2.
q Yes q No
Are you a veteran of the U.S. Armed Forces?
3.
q Yes q No
Will you be enrolled in a graduate or professional program (beyond a Bachelor’s degree)?
4.
q Yes q No
Are married or have you been married?
5.
q Yes q No
Are you an orphan or a ward of the court, or were you a ward of the court until age 18?
6.
q Yes q No
Do you have legal dependents (other than spouse)?
7.
q Yes q No
Are you on active duty with the military?
8.
q Yes q No
Have you been financially self sufficient for one year prior to the term in which you will enroll?
If yes, you may be required to furnish “clear and convincing” evidence.
If you answered yes to any question in SECTION B, please complete SECTIONS C & E. If you answered no to every question, please sign
SECTION E and have your parent or legal guardian complete SECTIONS D & E.
SECTION C: DOMICILE
1. Are you on active duty in the U.S. Armed Forces? __Yes __No; If “Yes,” does the current Leave and Earning Statement reflect Virginia withholdings
(taxes)? __Yes __No
Date of Entry: ____________ Official Duty Station:________________ Reporting Date: ______________ Duration of Orders: ______________
mm/dd/yyyy
State
mm/dd/yyyy
mm/dd/yyyy
2. Are you the dependent of an active duty member in the U.S. Armed Forces? ___Yes ___No; If “Yes,” does the current Leave and Earning Statement
reflect Virginia withholdings (taxes)? ____Yes ____No
Date of Entry: ___________ Official Duty Station:_________________ Reporting Date: ______________ Duration of Orders: _______________
mm/dd/yyyy
State
mm/dd/yyyy
mm/dd/yyyy
3. Are you retired or discharged from the U.S. Armed Forces? ____Yes ____No If “Yes,” date of discharge/retirement? ______________________
mm/dd/yyyy
4. Are you the dependent of someone retired or discharged from the U.S. Armed Forces? ____Yes ____No
If “Yes,” date of discharge/retirement? _____________________
mm/dd/yyyy
5. For the last year, did you (select only one):
q file Virginia income taxes on all earned income
q was a resident in a state without income tax
q file as a resident in another state
q had no taxable income
q file as a resident in Virginia and as a non-resident in another state
For the last year, did you:
6. q Yes q No
hold a valid Virginia Driver’s license? Date issued: _____/_____/_____
7. q Yes q No
have a Virginia DMV ID card? Date issued: _____/_____/_____
q Yes q No
hold a driver’s license from another state? If yes, what state? _________________________________
8. q Yes q No
own or operate a motor vehicle registered in Virginia? Virginia registration date: _____/_____/_____
q Yes q No
own or operate a motor vehicle registered in another state? If yes, what state? ________________________________
9. q Yes q No
been registered to vote in Virginia? Virginia registration date: _____/_____/_____
(Over)
q Yes q No
been a registered voter in another state? If yes, what state? _____________________________________________
SS-031
Domiciliary Reclassification Application Form
DOMICILE AFFIDAVIT To become eligible for in-state tuition, a student shall establish by clear and convincing evidence that for a period of at least one year im-
mediately prior to the first day of classes, he or she was domiciled in Virginia and has abandoned any previous domicile, or that the person on whom the student is
legally and financially dependent was domiciled in Virginia. This form must be completed if you are claiming entitlement to Virginia in-state tuition rates pursuant
to section 23.7-4, code of Virginia. All questions must be answered. Where not applicable answer N/A.
SECTION A: APPLICANT
SIS ID ________________________________
1.
Name of Applicant: __________________________________________________________________Birthday ______/______/_______
Last
First
Middle
Month
Day
Year
2.
Are you a U.S. Citizen? ____Yes ____No If “No,” are you a permanent resident? ____Yes ____No
If “Yes,” what is your “A number?” ________________________ If “No,” what is your immigration status? ____________________________
3.
How long have you lived in Virginia? _____________ years, ______________ months
4.
Where have you lived the last two years? List current address first:
From (mm/yr) To (mm/yr) Street Address
City
State
Zip
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
5.
q Yes q No Do your parents/legal guardian provide over half of your financial support or claim you as a tax dependent?
If no, go to #6. If yes, sign section E and have your parent/ legal guardian complete sections D & E
6.
q Yes q No
Do you wish to claim in-state tuition rates based on your Virginia domiciliary residency status?
If no, where will you retain legal domicile ?___________________________________________________________________
State
Country
If yes, continue to SECTION B. If no, go to #7
7.
q Yes q No Do you wish to claim in-state tuition based on your spouse’s domiciliary status?
If no, sign SECTION E. If yes, sign Section E & have your SPOUSE complete sections D & E
SECTION B: STUDENT STATUS
1.
q Yes q No
Will you be age 24 or older before the first day of classes?
2.
q Yes q No
Are you a veteran of the U.S. Armed Forces?
3.
q Yes q No
Will you be enrolled in a graduate or professional program (beyond a Bachelor’s degree)?
4.
q Yes q No
Are married or have you been married?
5.
q Yes q No
Are you an orphan or a ward of the court, or were you a ward of the court until age 18?
6.
q Yes q No
Do you have legal dependents (other than spouse)?
7.
q Yes q No
Are you on active duty with the military?
8.
q Yes q No
Have you been financially self sufficient for one year prior to the term in which you will enroll?
If yes, you may be required to furnish “clear and convincing” evidence.
If you answered yes to any question in SECTION B, please complete SECTIONS C & E. If you answered no to every question, please sign
SECTION E and have your parent or legal guardian complete SECTIONS D & E.
SECTION C: DOMICILE
1. Are you on active duty in the U.S. Armed Forces? __Yes __No; If “Yes,” does the current Leave and Earning Statement reflect Virginia withholdings
(taxes)? __Yes __No
Date of Entry: ____________ Official Duty Station:________________ Reporting Date: ______________ Duration of Orders: ______________
mm/dd/yyyy
State
mm/dd/yyyy
mm/dd/yyyy
2. Are you the dependent of an active duty member in the U.S. Armed Forces? ___Yes ___No; If “Yes,” does the current Leave and Earning Statement
reflect Virginia withholdings (taxes)? ____Yes ____No
Date of Entry: ___________ Official Duty Station:_________________ Reporting Date: ______________ Duration of Orders: _______________
mm/dd/yyyy
State
mm/dd/yyyy
mm/dd/yyyy
3. Are you retired or discharged from the U.S. Armed Forces? ____Yes ____No If “Yes,” date of discharge/retirement? ______________________
mm/dd/yyyy
4. Are you the dependent of someone retired or discharged from the U.S. Armed Forces? ____Yes ____No
If “Yes,” date of discharge/retirement? _____________________
mm/dd/yyyy
5. For the last year, did you (select only one):
q file Virginia income taxes on all earned income
q was a resident in a state without income tax
q file as a resident in another state
q had no taxable income
q file as a resident in Virginia and as a non-resident in another state
For the last year, did you:
6. q Yes q No
hold a valid Virginia Driver’s license? Date issued: _____/_____/_____
7. q Yes q No
have a Virginia DMV ID card? Date issued: _____/_____/_____
q Yes q No
hold a driver’s license from another state? If yes, what state? _________________________________
8. q Yes q No
own or operate a motor vehicle registered in Virginia? Virginia registration date: _____/_____/_____
q Yes q No
own or operate a motor vehicle registered in another state? If yes, what state? ________________________________
9. q Yes q No
been registered to vote in Virginia? Virginia registration date: _____/_____/_____
(Over)
q Yes q No
been a registered voter in another state? If yes, what state? _____________________________________________
10. Answer this question only if you have worked in Virginia but lived outside Virginia during the past 12 months.
q Yes q No Will you have lived outside Virginia, earned at least the equivalent of a full time wage salary, and paid income taxes to Virginia for at least one year
prior to the term in which the applicant will enroll?
Please continue to SECTION E
SECTION D: PARENT, LEGAL GUARDIAN OR SPOUSE
1. Name of Parent/Legal Guardian or Spouse: ______________________________________________________________________________
Last
First
Middle
2. Relationship to Applicant: q Parent q Spouse q Legal guardian (If legal guardian, must provide copy of court order.)
3. Are you a U.S. Citizen? ____Yes ____No If “No,” are you a permanent resident? ____Yes ____No
If “Yes,” what is your “A number?” ________________________ If “No,” what is your immigration status? ____________________________
4. How long have you lived in Virginia? ____________ years, ____________ months
5. Where have you lived the last two years? List current address first:
From (mm/yr) To (mm/yr)
Street Address
City
State
Zip
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
6. Are you on active duty in the U.S. Armed Forces? __Yes __No; If “Yes,” does the current Leave and Earning Statement reflect Virginia withholdings
(taxes)? __Yes __No
Date of Entry: ____________ Official Duty Station:__________________ Reporting Date: ______________ Duration of Orders: _____________
mm/dd/yyyy
State
mm/dd/yyyy
mm/dd/yyyy
7. Are you the dependent of an active duty member in the U.S. Armed Forces? ___Yes ___No; If “Yes,” does the current Leave and Earning Statement
reflect Virginia withholdings (taxes)? ____Yes ____No
Date of Entry: ____________ Official Duty Station:________________ Reporting Date: ______________ Duration of Orders: _______________
mm/dd/yyyy
State
mm/dd/yyyy
mm/dd/yyyy
8. Are you retired or discharged from the U.S. Armed Forces? ____Yes ____No If “Yes,” date of discharge/retirement? ______________________
mm/dd/yyyy
9. Are you the dependent of someone retired or discharged from the U.S. Armed Forces? ____Yes ____No
If “Yes,” date of discharge/retirement? ______________________
mm/dd/yyyy
10. q Yes q No Will you have claimed the applicant as a dependent on your federal and Virginia income tax returns for the twelve months prior to the
term in which the applicant will enroll?
11. q Yes q No Will you have provided over half of the applicants financial support for the entire 12 months prior to the term in which the applicant will enroll?
12. For the last year, did you (select only one):
q file Virginia income taxes on all earned income
q was a resident in a state without income tax
q file as a resident in another state
q had no taxable income
q file as a resident in Virginia and as a non-resident in another state
For the last year, did you:
13. q Yes q No
hold a valid Virginia Driver’s license? Date issued: _____/_____/_____
14. q Yes q No
have a Virginia DMV ID card? Date issued: _____/_____/_____
q Yes q No
hold a driver’s license from another state? If yes, what state? __________________________
15. q Yes q No
own or operate a motor vehicle registered in Virginia? Virginia registration date: _____/_____/_____
q Yes q No
own or operate a motor vehicle registered in another state? If yes, what state? _________________________________
16. q Yes q No
been registered to vote in Virginia? Virginia registration date: _____/_____/_____
q Yes q No
been a registered voter in another state? If yes, what state? ____________________________
17. Answer this question only if you have lived outside Virginia but work inside Virginia.
q Yes q No a. Will you have lived outside Virginia, earned at least the equivalent of a full time wage salary, and paid income taxes to Virginia for at least one
year prior to the term in which the applicant will enroll?
q Yes q No b. If the answer to 17 is yes, will the parent employed in Virginia have claimed the applicant as a dependent for federal and Virginia income tax
purposes for at least one year prior to the term in which the applicant will enroll?
Please complete SECTION E
SECTION E: SIGNATURES
The applicant must sign below or this application will not be processed. If SECTION D has been completed by a parent, legal guardian, or spouse, that individual
must also sign below.
I certify under penalty of disciplinary action that the information I have provided is true. I agree to furnish the college with supporting documentation
related to my application, if requested to do so. I understand my domicile decision may be appealed.
Signature of Applicant _________________________________________________________________________________ Date _______________
I certify that the information I have provided is true.
Signature of Parent, Legal Guardian, or Spouse ______________________________________________________________ Date ______________
FOR OFFICE USE ONLY
q Approved
q Disapproved
Signature _________________________________________________________ Date ______________________
7/12
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