Fill - Free fillable A RESIDENCY QUESTIONNAIRE (Cisco College) PDF form

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RESIDENCY QUESTIONNAIRE

The Texas Higher Education Coordinating Board rule 21.25 requires each student applying to enroll at an institution to respond to a set of core residency questions

for the purpose of determining the student’s eligibility for classification as a resident. Also, if you are seeking reclassification based on additional or changed

information, the college requires that the student complete a set of core residency questions and provide relevant supporting information as outlined on Page 4 of this

questionnaire.

*STUDENT ID OR SSN MUST BE PROVIDED

Part

Student Basic

Information

Last Name First Name

Student ID or SSN (required)*

First Term at Cisco College(Admit Term)

Street Address Apartment No.

City, State, Zip Code

Part

Enrollment

1. During the 12 months prior to the term for which you are applying, did

you attend a public college or university in Texas in a fall or spring term?

Yes ___ No ___

If you answered “no”, please continue to Part C.

If you answered “yes”, complete questions 2-5:

2. What Texas public institution did you last attend? (Give full name, not just initials.)

3. In which terms were you last enrolled? (check all that apply)

4. During your last semester at a Texas public institution, did you pay resident (in-state) or

nonresident (out-of-state) tuition?

___ resident (in-state)

___ nonresident (out-of-state)

___ unknown

5. If you paid in-state tuition at your last institution, was it because you were classified as a

resident or because you were a nonresident who received a waiver?

___ resident

___ nonresident with a waiver

___ unknown

IMPORTANT: If you were enrolled at a Texas public institution during a fall or spring semester within the previous 12 months and were classified as

a Texas resident, skip to Part I, sign and date this form and submit it to your institution. If you were not enrolled at a Texas public institution during

a fall or spring semester within the previous 12 months, or if you were enrolled but classified as a nonresident, proceed to Part C.

Part

Residency

Claim

Are you a resident of Texas? Yes ___ No ___

If you answered yes, continue to Part D.

If you answered no, complete the following question and continue to Part I.

Of what state or country are you a resident? __________________

If you are uncertain, continue to Part D.

Part

Acquisition

of High

School

Diploma or

GED

1. a. Did you graduate or will you graduate from high school or complete a GED in TX prior to

the term for which you are applying?

Yes ___ No ___

1. b. If you graduated or will graduate from high school, what was the name and city of the

school?

Yes ___ No ___

2. Did you live or will you have lived in TX the 36 months leading up to high school graduation or

completion of the GED?

3. When you begin the semester for which you are applying, will you have lived in TX for the

previous 12 months?

Yes ___ No ___

4. Are you a U.S. Citizen or Permanent Resident? Yes ___ No ___

Instructions to Part D:

1. If you answered “no” to question 1a or 2 or 3, continue to Part E.

2. If you answered “yes” to all four questions, skip to Part I.

3. If you answered “yes” to questions 1, 2 and 3, but “no” to question 4, complete the Residency Affidavit (available at Enrollment Services

and online) and submit this form with the affidavit to your institution.

Mail or fax form to:

Cisco College, Admissions Office/Residency Official

101 College Heights Cisco, TX 76437

Fax: 254-442-1449

Page 2 of 4

Part

Basis of

Claim to

Residency

TO BE COMPLETED BY EVERYONE WHO DID NOT ANSWER “YES” TO QUESTIONS 1a, 2, AND 3 OF PART D.

1. Do you file your own federal income tax as an independent tax payer?

(An independent tax payer should not be claimed as a dependent for tax purposes by

another

person. If

you file a joint return with your spouse, answer “yes.”

)

es ___ No ___

2. Are you claimed as a dependent or are you eligible to be claimed as a dependent by a parent

or court-

appointed legal guardian?

(To be eligible to be claimed as a dependent, your parent or legal guardian must prov

ide at

least one-half of

your support. A step-parent does not qualify as a parent if he/she ha

s not

legally

adopted you.)

Yes ___ No ___

3. If you answered “No” to both questions above, who provides the majority of your support?

Instructions to Part E.

If you answered “yes” to question 1, and “no” to question 2, continue to Part F

If you answered “yes” to question 2, skip to Part G

If you answered “yes” to both questions 1 and 2, skip to Part G.

If you answered “no” to 1 and 2 and “self” to question 3, continue to Part F

If you answered “no” to 1 and 2 and “parent or guardian” to question 3, skip to Part G

If you answered “no” to 1 and 2 and “other” to question 3, skip to Part H and provide an explanation, and complete Part I

Part

Questions for students who answered “Yes” to Question 1 or “Self” to Question 3 of PART E.

1. Are you a U.S. Citizen? Yes ___ No ___

2. Are you a Permanent Resident of the U.S.?

(U.S. Citizens check “no”.)

Yes ___ No ___

3. Are you a foreign national whose application for Permanent Resident Status has been

preliminarily

reviewed? (You should have received a fee/filing receipt or Notice of Action (I-797)

from USCIS showing your I-485 has been reviewed and has not been rejected).

Yes ___ No ___

4. Are you a foreign national here with a visa or are you a Refugee, Asylee, Parolee or here

under T

emporary Protective Status? If so, indicate which.

Yes ___ No ___

Visa type:

5. Do you currently live in Texas? If you are out of state due to a temporary assignment by your

employer or another temporary purpose, please check “no” and explain in Part H.

Yes ___ No ___

6. a. If you currently live in Texas, how long have you been living here?

Years: Months:

6. b. What is your main purpose for being in the state? If for reasons other than those listed,

give an explanation in Part H.

Go to College [ ]

Establish/maintain a home [ ]

Work Assignment [ ]

7. If you are a member of the U.S. military:

a. Is Texas

your Home of Record

b. If not,

what state will have been listed as your military legal residence for tax purpos

es on

your

Leave and Earnings Statement for the 12 months prior to enrollment?

7a. Yes ___ No ___

7b.

8. Do either of the following apply to you? (Check all that apply)

a. Hold the title (Warranty Deed, Deed of Trust, or other similar instrument that is effective to hold title) to residential real property

in Texa

yes, date acquired: _______________________

b. Have o

wnership interest and customarily manage a business in Texas without the intention of liquidation in the fores

eeable

future?

yes, date acquired: _______________________

9. While living in Texas, have you: (Check all that apply)

a. Been gainfull

y employed for a period of at least 12 consecutive m

onths? (Gainful

emplo

yment requires an average employment of at least 20 hours per week for one

year or

earnings equal to

at least half of tuition and living expenses for one 9-month academic y

ear.

Emplo

yment conditioned on student status such as work-study, the re

ceipt of stipends,

fellow

ships or research or teaching assistanceships does not constitute gainful employment.)

b. Received primar

y support through services from a social service agency for a perio

d of at

least 12 consecutive months?

9a.

Yes ___ No ___

9b. Yes ___ No ___

10. Spouse:

a. Are you married to a person who has been classified as a Texas resident by a Te

xas

public institut

ion or who could answer “yes” to any part of question 8 or 9?

b. If

yes, indicate which question (and which part of the question) could be answered yes by

your spouse:

c. How long

will you have been married to the Texas resident prior to enrollment?

10a. Yes ___ No ___

10b. Question # _____

10c. Years: ____ Months _____

Skip Part G and Continue to Part H.

Page 3 of 4

Part

Questions for students who answered “Yes” to Question 2 of Part E or who answered “Parent or Guardian”

to Question 3 of PART E.

1. Is the parent or legal guardian upon whom you base your claim of residency a U.S. citizen? Yes ___ No ___

2. Is the parent or legal guardian upon whom you base your claim of residency a Permanent

Resident?

(If U.S. Citizen, check “no”.)

es ___ No ___

3. Is this parent or legal guardian a foreign national whose application for Permanent Resident

Status has been

preliminarily reviewed? (He or she should have received a fee/filing receipt or

Notice of Action (I-797) from the USCIS showing his or her I-485 has been reviewed and has

not been rejected)

Yes ___ No ___

4. Is this parent or legal guardian a foreign national here with a visa or a Refugee, Asylee,

Parolee or he

re under Temporary Protective Status? If so, indicate which.

Yes ___ No ___

Visa type:

5. Does this parent or guardian currently live in Texas? If he or she is out of state due to a

tempora

ry assignment by his or her employer or another temporary purpose, please check “no”

and explain in Part H.

Yes ___ No ___

6. a. If he or she is currently living in Texas, how long has he or she been living here?

Years: Months:

6. b. What is your parent’s or legal guardian’s main purpose for being in the state? If for reasons

other than those listed, give an explanation in Part H.

Go to College [ ]

Establish/maintain a home [ ]

Work Assignment [ ]

7. If you are a member of the U.S. military:

a. If he or

she is a member of the U.S. military, is Texas his or her Home of Record

b. If not,

what state will have been listed as his or her military legal residence for tax

purposes

on his or her Le

ave and Earnings Statement for the 12 months prior to enrollment?

7a. Yes ___ No ___

7b.

8. Do any of the following apply to your parent or guardian? (Check all that apply)

a. Hold the title (Warranty Deed, Deed of Trust or other similar instrument that is effective to hold title) to residential real property

in Texa

yes, date acquired: _______________________

b. Have o

wnership interest and customarily manage a business In Texas without the intention of liquidation in the fores

eeable

future?

yes, date acquired: _______________________

9. While living in Texas, has your parent or guardian: (Check all that apply)

a. Been gainfull

y employed for a period of at least 12 consecutive m

onths? (Gainful

emplo

yment requires an average employment of at least 20 hours per week for one

year or

earnings equal to

at least half of tuition and living expenses for one 9-month academic y

ear.

Emplo

yment conditioned on student status such as work-study, the re

ceipt of stipends,

fellow

ships, or research or teaching assistanceships does not constitute gainful employment.)

b. Received services from a social service

agency

for a period of at l

east 12 consecutive

months? Note: th

e dollar value of social services received may be combined with ear

nings to

total at least one-

half of tuition and living expenses for one 9-month academic year.

9a. Yes ___ No ___

9b. Yes ___ No ___

10. Spouse:

a. Is your parent or legal guardian married to a person who has been classifi

ed as a Texas

resident b

y a Texas public institution or who could answer “yes” to any part of question 8 or

b. If

yes, indicate which question (and which part of the question) could be answered yes by

your parent or guardian’s spouse:

c. How long

will your parent or guardian have been married to the Texas resident prio

r to

enrollment?

10a. Yes ___ No ___

10b. Question # _____

10c. Years: ____ Months _____

Continue to Part H.

Part

General

Comments

Is there any additional information that you believe your college/university should know in evaluating your eligibility to be classified

as a resident?

If so, please provide it below (attach additional sheets as necessary):

Part

Certification

of Residency

I understand that officials of my college/university will use the information submitted on this form to determine my status for

residency eligibility. I authorize the college/university to verify the information I have provided. I agree to notify the proper

officials of the institution of any changes in the information provided. I certify that the information on this application is complete

and correct and I understand that the submission of false information is grounds for rejection of my application, withdrawal of

any offer of acceptance, cancellation of enrollment and/or appropriate disciplinary action.

Signature: Date:

Page 4 of 4

Documentation to Support Establishing and Maintaining Domicile in Texas

The following documentation may be requested by the institution regarding a person’s responses to the Core Residency Questions.

Documents that may be used as proof that:

(1) The person or the dependent’s parent established domicile in Texas, and

(2) The person or the dependent’s parent has maintained domicile in Texas continuously for at least 12 consecutive months immediately

preceding the census date of the term in which the person enrolls,

include but are not limited to the following:

Part A

Documents that may Support the Establishment of a Domicile in Texas and Maintenance of Domicile in Texas

1. SIGNIFICANT GAINFUL EMPLOYMENT

a. An employer’s statement of dates of employment in Texas (beginning and current or ending dates) that encompass at least 12

consecutive months immediately preceding the census date of the term in which the person enrolls.

b. Other documents that show the person or the dependent’s parent, for at least 12 consecutive months immediately preceding the

census date of the term in which the person enrolls:

1) has been engaged in employment intended to provide an income to the person or allow the person to avoid the expense of paying

another to perform tasks (as in child care) that is sufficient to provide at least one-half of the individual’s tuition and living

expenses or represents an average of at least 20 hours per week; or

2) is self-employed in Texas or is living off his/her earnings; or

3) is primarily supported by public assistance in Texas.

c. For a homeless person, written statements from the office of one or more social service agencies located in Texas that attest to the

provision of services to the homeless person for the 12 consecutive months immediately preceding the census date of the term in

which the person enrolls.

2. SOLE OR JOINT MARITAL OWNERSHIP OF RESIDENTIAL REAL PROPERTY

Title to residential real property in Texas with documentation to verify 12 consecutive months of ownership immediately preceding the

census date of the term in which the person enrolls, such as a Warranty Deed, with the person or the dependent’s parent having

established and maintained domicile at that residence.

3. MARRIAGE TO A PERSON WHO HAS ESTABLISHED AND MAINTAINED DOMICILE IN TEXAS

Marriage Certificate or Declaration of Registration of Informal Marriage with documentation to support that spouse has established and

maintained domicile in Texas for the 12 consecutive months preceding the census date of the term in which the person enrolls.

4. OWNERSHIP OF A BUSINESS ENTITY

Documents that evidence the organization of the business in Texas that reflect the ownership interest of the person or dependent’s

parent, and the customary management of the business by the person or dependent’s parent without the intention of liquidation for the

foreseeable future.

Part B

Documents that May Provide Support to a Claim of Maintaining a Domicile in Texas for the 12 Consecutive Months Immediately

Preceding the Census Date of the Term in which the Person Enrolls

1. Utility bills for the 12 consecutive months preceding the census date;

2. A Texas high school transcript for full senior year immediately preceding the census date;

3. A transcript from a Texas institution showing presence in the state for the 12 consecutive months preceding the census date;

4. A Texas driver’s license or Texas ID card that has not expired and, if it reflects an origination date, shows an origination date at least

12 months prior to the census date;

5. Cancelled checks that reflect a Texas residence for the 12 consecutive months preceding the census date;

6. A current credit report that documents the length and place of residence of the person or the dependent’s parent to be in Texas and

the length of residence to be at least 12 consecutive months preceding the census date.

7. Texas voter registration card that was issued at least 12 months prior to the census date.

8. Pay stubs for the 12 consecutive months immediately preceding the census date, reflecting significant gainful employment in Texas;

9. Bank statements reflecting a Texas address for the 12 consecutive months immediately preceding the census date;

10. Written statements from the office of one or more social service agencies, attesting to the provision of services for at least the 12

consecutive months immediately preceding the census date.

11. Lease or rental of residential real property in the name of the person or the dependent’s parent for the 12 consecutive months

immediately preceding the census date.

Part C

Other Documents that May be Used to Lend Support To or Clarify

an Individual’s Claim of Domicile or Residence, as Appropriate, in Texas

Among other documents that may be used to lend support to or clarify an individual’s claim of having established and maintained domicile or

residence, as appropriate, in Texas are the following:

1. Tax return of the student or parent(s).

2. Visa, passport or other pertinent immigration documents.

3. Leave and Earnings Statements (LES).

4. Documents or statements to clarify answers to Core Residency Questions.

5. A Texas high school transcript to verify thirty-six months’ presence in the state and graduation from a Texas high school.

6. State or local licenses to conduct a business or practice a profession in this state.

The attached IRS form W-9S MUST be completed, signed and returned with your

Residency Questionnaire form. The second box marked “Taxpayer identification

number” refers to your social security number. This box is for the purpose of

certifying under penalty and perjury that the information provided is true and

correct.

PLEASE NOTE: If your address or name changes you are responsible for reporting

that change to Cisco College. Addresses can be updated through your Campus

Connect account. Name changes require supporting documents and can only be

made through the Admissions/Enrollment Services office.

Give form to the

requester. Do not

send to the IRS.

Form

W-9S

Request for Student’s or Borrower’s Taxpayer

Identification Number and Certification

(Rev. March 2008)

Department of the Treasury

Internal Revenue Service

Name of student or borrower (see instructions)

City, state, and ZIP code

Print or type

Student or Borrower Identification (All must complete.)

Student Loan Certification (Complete for student loans only.)

I certify that all of the loan proceeds are solely to pay for qualified higher education expenses.

Sign

Here

Signature of borrower

Date

Form W-9S (Rev. 3-2008)

Part I

Address (number, street, and apt. or suite no.)

Cat. No. 25240C

Taxpayer identification number

Part II

General Instructions

Purpose of form. An eligible educational institution, such as

a college or university, or a lender of a student loan must get

your correct identifying number to file certain information

returns with the IRS and to furnish a statement to you. For

students, this will be your social security number (SSN) or, if

you are not eligible to obtain an SSN, your individual

taxpayer identification number (ITIN). The returns they must

file contain information about qualified tuition and related

expenses (Form 1098-T, Tuition Statement) and student loan

interest (Form 1098-E, Student Loan Interest Statement). The

information about your tuition will help to determine whether

you, or the person who can claim you as a dependent, may

take either the tuition and fees deduction or claim an

education credit to reduce federal income tax. The

information about your student loan interest will help to

determine your deduction for such interest. For more

information, see Pub. 970, Tax Benefits for Education.

Use Form W-9S to give your correct SSN or ITIN to the

person requesting it and, if applicable, to certify that the

proceeds of a loan are being used, or will be used, solely to

pay for qualified higher education expenses (defined on page

2). You are required to provide the requested information.

Note. The educational institution or lender may request your

SSN or ITIN and certification on paper or electronically.

Specific Instructions

Part I. Student or Borrower Identification

Name and address. Enter the name and mailing address of

the student if the request for the student’s SSN or ITIN is

being made because of tuition payments. Enter the name

Taxpayer’s identifying number. Enter your SSN or ITIN. If

you do not have an SSN or ITIN and you have applied for

one or you intend to apply for one soon, write “Applied For”

in the space provided.

How to get an SSN or ITIN. To apply for an SSN, use Form

SS-5, Application for a Social Security Card, that you can get

from your local Social Security Administration office or get

this form online at www.ssa.gov/online. You may also get this

form by calling 1-800-772-1213.

Part II. Student Loan Certification

Requester Information (Optional)

Part III

Requester’s name and address

Tuition account number

Loan account number

Note. If you pay tuition to and have a student loan from the

same educational institution and the student is not the loan

borrower (for example, the borrower is the student’s parent),

complete two Forms W-9S, one for the student and one for

the loan borrower.

If your loan is a student loan incurred solely to pay for

qualified higher education expenses, sign the certification in

Part II. If you do not sign the certification, the lender may not

issue or file Form 1098-E for student loan interest on your

behalf. Do not sign the certification for a mixed use loan

because such a loan is not used solely for qualified higher

education expenses. However, you may sign the certification

for a revolving line of credit or similar loan if you use the line

of credit solely to pay for qualified higher education

expenses.

You must complete this part.

For Privacy Act Notice, see page 2.

and mailing address of the borrower if the request for the

borrower’s SSN or ITIN is being made because of a student

loan.

To apply for an ITIN because you are not eligible to get an

SSN, use Form W-7, Application for IRS Individual Taxpayer

Identification Number, that you can get from the IRS website

at www.irs.gov or by calling 1-800-TAX-FORM

(1-800-829-3676).

Penalties

Failure to furnish correct SSN or ITIN. If you fail to furnish

your correct SSN or ITIN to the requester, you are subject to

a penalty of $50 unless your failure is due to reasonable

cause and not to willful neglect.

Misuse of SSN or ITIN. If the requester discloses or uses

your SSN or ITIN in violation of federal law, the requester

may be subject to civil and criminal penalties.

Page 2

Form W-9S (Rev. 3-2008)

Part III. Requester Information

This part is not required to be completed. It is provided for

the convenience of the requester to help identify the account

to which this Form W-9S relates. The requester may enter its

name and address and a tuition or loan account number.

Note. For information about electronic submission of Forms

W-9S, see the Instructions for Forms 1098-E and 1098-T.

Qualified higher education expenses. These expenses are

the costs of attending an eligible educational institution,

including graduate school, on at least a half-time basis.

Generally, these costs include tuition and certain related

expenses. See Pub. 970 for more information.

Secure Your Tax Records From Identity

Theft

Identity theft occurs when someone uses your personal

information such as your name, taxpayer identification

number (TIN), or other identifying information, without your

permission, to commit fraud or other crimes. An identity thief

may use your SSN to get a job or may file a tax return using

your TIN to receive a refund.

The IRS does not initiate contacts with taxpayers via

emails. Also, the IRS does not request personal detailed

information through email or ask taxpayers for the PIN

numbers, passwords, or similar secret access information for

their credit card, bank, or other financial accounts.

Privacy Act Notice

Section 6109 of the Internal Revenue Code requires you to

give your correct SSN or ITIN to persons who must file

information returns with the IRS to report certain information.

The IRS uses the numbers for identification purposes and to

help verify the accuracy of your tax return. The IRS may also

provide this information to the Department of Justice for civil

and criminal litigation and to cities, states, the District of

Columbia, and U.S. possessions to carry out their tax laws.

We may also disclose this information to other countries

under a tax treaty, or to federal and state agencies to

enforce federal nontax criminal laws, or to federal law

enforcement and intelligence agencies to combat terrorism.

Protect yourself from suspicious emails or phishing

schemes. Phishing is the creation and use of email and

websites designed to mimic legitimate business emails and

websites. The most common act is sending an email to a

user falsely claiming to be an established legitimate

enterprise in an attempt to scam the user into surrendering

private information that will be used for identity theft.

To reduce your risk:

● Protect your TIN,

● Ensure the requester is protecting your TIN, and

● Be careful when choosing a tax preparer.

Call the IRS at 1-800-829-1040 if you think your identity

has been used inappropriately for tax purposes.

Victims of identity theft who are experiencing economic

harm or a system problem, or are seeking help in resolving

tax problems that have not been resolved through normal

channels, may be eligible for Taxpayer Advocate Service

(TAS) assistance. You can reach TAS by calling the TAS

toll-free at 1-877-777-4778 or TTY/TDD 1-800-829-4059.

If you receive an unsolicited email claiming to be from the

IRS, forward this message to phishing@irs.gov. You may also

report misuse of the IRS name, logo, or other IRS personal

property to the Treasury Inspector General for Tax

Administration at 1-800-366-4484. You can forward

suspicious emails to the Federal Trade Commission at:

spam@uce.gov or contact them at www.ftc.gov/idtheft or

1-877-IDTHEFT (1-877-438-4338).

Visit the IRS website at www.irs.gov to learn more about

identity theft and how to reduce your risk.

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