College Residency Application
2700 Evergreen Parkway NW Olympia, WA 98505
Directions: Please print clearly and answer each question. Incomplete or illegible forms cannot be considered and will be returned. Falsification or intentionally erroneous information is
subject to perjury under the laws of the State of Washington, RCW 9A.72.085. All information will be kept confidential in accordance with the Family Educational Rights and Privacy Act of
1974. Once a domicile is established in Washington, it must continue for one year before you are eligible for resident tuition.
Complete form in full and attach required
documentation.
SECTION 1
Name (Last, First, MI)
Phone Number
FOR OFFICE USE ONLY
Type
Address (Street, State, Zip)
ID Number
Status
DEP INDEP
E-mail Address
Birth City, State, Country Birth Date
Today's Date
1. Last High School Attended _________________________________________ State ___________ Year Graduated _____________
Effective Date
2. For what term are you now seeking
residence classification? Year 20___
Fall Winter Spring Summer
If you have previously applied at this institution for a change in residence status, indicate: Term __________ Year __________
Resident Non-Resident
3. Class Standing:
Undergraduate Graduate Professional School: _______________________________________
____________________________________
Residence Classification Officer
4. At this Institution, you are or will be enrolled as a: New Student Continuing Student Returning Former Student
If continuing or former student, give number of credit hours for which you were registered during each of the last three terms and identify each term by session and year:
Credits ______ Term __________ Year __________ | Credits _______ Term __________ Year ___________ | Credits _______ Term __________ Year __________
5. Country of citizenship:
If not USA, answer 5a, 5b and 5c. If yes to 5a, 5b or 5c, attach a copy of
your U.S. Permanent Resident card, Form I-94 or other immigration
documentation.
5b. Do you hold "Refugee-Parolee," "Conditional Entrant" or PRUCOL status?
Yes No
Note: An immigrant refugee, and the spouse and dependent children of such refugee, may be
exempted from paying the nonresident tuition fees differential if the refugee (a) is on parole
status, (b) has received an immigrant visa, or (c) has applied for U.S. citizenship.
5a. Do you hold permanent or temporary resident immigration status?
Yes No
5c. Do you hold a visa classification of A, E, G, I or K?
Yes No
6. Have you received financial assistance from a state governmental unit or
agency during the past twelve months?
Yes No
If yes, indicate state, agency, type of assistance, disbursement dates, etc.
7. Will you be receiving state financial assistance during the next twelve months?
Yes No
If yes, indicate state, agency, type of assistance, disbursement dates, etc.
SECTION 2
1. Are you applying for resident status as a dependent
student whose parent or court -appointed legal guardian
has maintained a bona fide domicile in the State of
Washington for at least one year?
Yes No
If yes, your parent or legal guardian must complete SECTION 3 of this form, providing proof of his/her
Washington domicile and all requested supporting documentation. Verification of your dependent status
must be documented by submitting a true and correct copy of your parent's or legal guardian's state and
federal income tax return for the most recent tax year. The extent of the disclosure required concerning
the parent's or legal guardian's state and federal tax returns is limited to the listing of dependents claimed
and the signature of the taxpayer and shall not require disclosure of financial information contained in the
returns.
2. Are you applying for resident status as a financially
Independent student?
Yes No
If yes, you must complete Section 3 of this form and provide all requested supporting documentation.
2a. Student's Sworn Statement:
I have not been and will not be claimed as an exemption for federal Income tax purposes by any person except myself or my spouse for the current calendar year and for the
calendar year immediately prior to the year in which this application is made; and I have not received and will not receive significant financial assistance in any form directly
or indirectly from parents, relatives, legal guardians or others for the current year and for the calendar year immediately prior to the year in which this application is made.
Signature _________________________________________________________________________________________________ Date ___________________________
2b. To further substantiate your financial Independence, you are required to submit appropriate documentation , including but not limited to:
A true and correct copy of your state and federal income tax return for the calendar year immediately prior to the year in which this application is made. If you did not file a state
or federal income tax return because of minimal or no taxable income, documented information concerning the receipt of such nontaxable income must be submitted.
A true and correct copy of your W2 forms filed for the previous calendar year.
Other documented financial resources, which may include but are not limited to, the sale of personal or real property, trust fund, state or financial assistance, gifts, loans or
earnings of the spouse of a married student.
If you are 24 or younger, provide a true and correct copy of the first and signature page of the state and federal tax return of your parents, legally appointed guardians, or person
or persons who have legal custody of you for the calendar year immediately prior to the year in which this application is made. The extent of the disclosure required concerning
the parent's or legal guardian's state and federal tax returns is limited to the listing of dependents claimed and the signature of the taxpayer and shall not require disclosure of
financial information contained in the returns
.
SECTION 3 Do not leave any questions blank. No decision can be made unless all questions are completed and all required documentation is
submitted.
1. This section is being completed and signed by:
Parent Legal Guardian Student
Date of your arrival in Washington :
Month ________ Day _______ Year ______
Date you took action to officially declare Washington as your
permanent, legal domicile:
Month ________ Day _______ Year ______
Purpose of moving to Washington:
2. List chronologically your employment and physical residence for the last two years giving exact information as requested below. If you were not employed, list your physical residence for
the last two years. Attach additional page if necessary.
DATES OF EMPLOYMENT LOCATION OCCUPATION HOME ADDRESS
Mo. Day Yr. Mo. Day Yr. City State Employer Hrs/wk Street City State
Note: You must provide proof of your physical presence in Washington the past 12 months (e.g. copies of rent receipts, lease or home purchase agreements, cancelled rent
checks, letter from landlord, letter from employer, etc.).
3. If you were out of Washington during the last 12 months, give dates, and reasons for your absence:
DATES OF ABSENCE LOCATION PURPOSE OF ABSENCE
Mo. Day Yr. Mo. Day Yr. City State
4. Have you ever
registered to vote
in any state?
Yes No
If yes, attach a
copy of your
current voter's
card.
If yes, list date, city and state for your last two registrations.
Date ____________ City __________________________ State ________ Date Voted ____________
Date ____________ City __________________________ State ________ Date Voted ____________
5. Do you own or use any
motor vehicles, RV’s,
boats or mobile homes
in any state?
If yes, give type of vehicle, license number, state and dates of registry. You must attach a copy of vehicle registration (not the title).
Type of vehicle _______________License Number _________________ State ______ Date of Purchase___________ Date of Registry ___________
Type of vehicle _______________ License Number ________________ State _______Date of Purchase ___________ Date of Registry ___________
Yes No
6. Do you have a valid
driver’s license in any
state?
If yes, you must attach
a copy of your current
driver's license.
If yes, in what state:
_________________________
When did you first obtain a driver's license in that state?
Date ______________________________
Yes No
Previous driver's
license?
Yes No
If yes, in what state:
_________________________
When did you first obtain a driver's license in that state?
Date ______________________________
7. Do you have a bank
account?
Yes No
If yes, please attach
documentation of date
you opened account.
If yes, since what date?
_________________________
Name of Bank _______________________ Branch _______________
City ________________________________ State ________________
8. Have you ever paid
in-state tuition at any
public institution of
higher education?
Yes No
If yes, date of last term __________________________________________
Name of Institution _____________________________________________
Dates Attended: From _____________________ To __________________
8a. Have you ever attended a Washington college/university for more than 6
hours per term?
Yes No
If yes, where _________________________________________________
Dates attended From____________________ To ___________________
9. Are you a US Citizen?
Yes No
If no, attach a copy of your U.S. Permanent Resident card, I-94 or other immigration documentation.
10. List business or
professional licenses
(name & state of issue)
______________________________________________________________________________________________________________
11. Other (evidence of coverage for medical, life, automobile or property insurance, state licenses such as hunting or fishing, etc.) Explain: __________________________
__________________________________________________________________________________________________________________________________________________
NOTICE:
Residence questionnaires requesting a change in residence classification shall be accepted up to the thirtieth calendar day following the first day of the quarter/semester for
which application is made. Questionnaires received after that date shall be considered to have been filed as of the first day of the subsequent quarter/semester.
STATEMENT OF INTENT You MUST print and sign this form for submission. Digital signatures are not accepted.
I certify that I have declared
Washington as my true, fixed, and
permanent place of habitation.
Signature of Parent (if completing SECTION 3) ___________________________________________ Date ____________________
CERTIFICATION
Parent Address (Street, City, State) ______________________________________________________________________________
I certify under penalty of perjury under
the laws of the State of Washington,
RCW 9A.72.085 that the foregoing
and all supporting documentation are
true and correct.
Signature of Student _________________________________________________________________ Date _____________________
AG Form #151 – Revised 6/03/08– AG Approval
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