Fillable APPLICATION FOR RE-CLASSIFICATION OF STUDENT'S DOMICILE STATUS (J Sargeant Reynolds Community College)

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APPLICATION FOR RE-CLASSIFICATION OF STUDENT'S DOMICILE STATUS (J Sargeant Reynolds Community College)

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BROWSE J SARGEANT REYNOLDS COMMUNITY COLLEGE FORMS

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JSRCC Form 11-0010 03/08
APPLICATION FOR RE-CLASSIFICATION OF
STUDENT'S DOMICILE STATUS
NAME OF APPLICANT _____________________________________________________
SOCIAL SECURITY # _____________________EMPL ID __________________________
This application is to present your appeal for the eligibility for in-state tuition. You may not request
Virginia domiciliary status retroactively or for previous terms. The appeal should be submitted two weeks
before the beginning of the semester. Continuing
students should submit appeals by:
August 1 for fall semester
December 1 for spring semester
April 1 for summer session
• If you are 24 years old and financially independent by the first day of the next semester, you must
complete the Student Appeal Form.
• If you are under 24 years old and unmarried or are financially dependent on your parents/legal guardians
or spouse by the first day of the next semester, you must complete the Student Appeal Form and your
parent, legal guardian or supporting spouse must complete the Parent/ Legal Guardian or Supporting
Spouse Form.
The completed form(s) and supporting documentation will be reviewed in compliance with Section 23-
7.4 of the Code of Virginia to determine your eligibility. A copy of the Code and the State regulations can be
viewed at a Student Success Center or at our web site: www.reynolds.edu under Paying for College.
Incomplete information and/or inadequate documentation will cause delays in processing and may negatively
affect the College's decision.
Section 2.12 of the SCHEV Guidelines
states that in cases where a student has knowingly provided
erroneous information, the College may change the student's status retroactively to the term for which the
fraudulent application was filed, bill for the tuition differential, and take action for dismissal.
If you need assistance completing this form, contact the Domicile Review Officer at 523-5029.
Return the form and supporting documents to: Central Admissions and Records, P O Box 85622,
Richmond, VA 23285-5622, or to a Campus Success Center.
Information and documentation to be returned to Central Admissions and Records by: ________
[ ] Parent’s [ ] Spouse’s [ ] Student’s Copy of current federal income tax return
[ ] Parent’s [ ] Spouse’s [ ] Student’s Copy of current state income tax return
[ ] Parent’s [ ] Spouse’s [ ] Student’s Copy of Virginia’s driver’s license
[ ] Parent’s [ ] Spouse’s [ ] Student’s Copy of Virginia voter’s registration card
[ ] Parent’s [ ] Spouse’s [ ] Student’s Copy of Virginia motor vehicle registration
[ ] Parent’s [ ] Spouse’s [ ] Student’s Copy of document to verify date you first moved to Virginia (i.e.
apartment lease/house closing statement, official employment
verification, etc.)
[ ] Parent or Legal Guardian [ ] Spouse Complete Parent/Legal Guardian or Spouse Supplemental
Application
JSRCC Form 11-0010 03/08
STUDENT APPEAL FORM
Date of Application EMPL ID ______________Social Security No. ______
Full Name: ________________________________________________________________
Last First MI Maiden, Family, or Other
Current Address: ___________________________________________________________
Email Address: ___
Telephone Number(s): Home
Work ______ __________
Date of Birth:
Marital Status: Sex: _____
Citizenship: (a) Choose one: [ ] U.S. Citizen [ ] Permanent Resident
[ ] Political Asylum/Refugee [ ] Temporary Visa [ ] Other
(b) If you are not a U.S. citizen, please specify:
Country of Origin Type of Visa Date of Issue Expiration Date
1. Residency in Virginia:
From
Month/Day/Year
To
Month\Day/Year
City and State
2. Residency outside Virginia:
From
Month\Day/Year
To
Month/Day/Year
City and State
3. If you have lived outside of Virginia during the past five years, please explain:
_______________________________________________________________________
_______________________________________________________________________
JSRCC Form 11-0010 03/08
4. Education: List ALL high schools, colleges and universities attended and indicate classification
(in-state or out-of-state tuition).
School
From
Mo/Yr
To
Mo/Yr
State
Degree
Earned
Classification
5. Attendance at J. Sargeant Reynolds Community College:
(a) Date of application:_____________
6. Status during the past year: Student: full-time _____ part-time ______ none _____
(Check all that apply) Employment: full-time _____ part-time ______ none _____
7. Employment: List all employment during the last three years:
Employer
Hrs/Wk City and State
From
M/D/Y
To
M/D/Y
Salary
8. Were state income taxes withheld from your income for the prior tax year?
YES [ ] NO [ ]. If YES: To what state? _____ Beginning on what date:_______________
9. Did you file a Virginia state tax return for the most recent tax year? YES [ ] NO [ ]
If YES: Did you file as a:
Resident [ ] Non-resident [ ] Part-year resident [ ] Year: ______________
If no: Please explain ____________________________________________
10. Are you a registered voter?
YES [ ] NO [ ] If YES, in which state? ________________ Registration Date:_______
11. Did you own or operate a motor vehicle during the past year?
YES [ ] NO [ ] If YES: Was it registered in Virginia in the past year? YES [ ] NO [ ]
If NO: In which state was it registered during the past year? __________________
Date registered: ________________ in whose name was it registered? _______________
12. Do you have a valid Virginia driver’s license? YES [ ] NO [ ] Date issued:________
14. Military Service:
(a) Are you a member of the armed forces? YES [ ] NO [ ]
(b) Are you a dependent of a military parent or spouse? YES [ ] NO [ ]
(c) Provide your military information:
JSRCC Form 11-0010 03/08
Applicant Parent/spouse
1. Date of entering service
2. Home of record on entering
3. Changes in home of record
(dates and states)
4. Duty Station
5. Expected date of discharge
6. State currently claimed for
tax purposes (date)
7. State to which you last paid
tax on your military income
15. Are you requesting a special tuition rate as the employee of an agency or institution that
has a special tuition-rate contract with this J. Sargeant Reynolds Community College?
YES [ ] NO [ ] Name of Employer:_________________________
16. Why did you move to Virginia?
________________________________________________________________________
___________________________________________________________________________
17. Do you intend to remain in Virginia indefinitely? YES [ ] NO [ ]
If YES
, please list any additional factors including social or economic ties to Virginia which you
believe should be considered:
18. Have you accepted an offer of full-time employment with a Virginia employer? YES [ ] NO [ ]
Name and address of employer:
_______________________________________________________________________
* * * * * *
I hereby certify that the information given is true and accurate. I also understand that if I provide erroneous
information in an attempt to evade payment of out-of-state fees, I shall be charged out-of-state fees for each
term attended and may be subject to dismissal from the institution.
___________________________________________________________________________
Student's Signature Date
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JSRCC Form 11-0010 03/08
PARENT/LEGAL GUARDIAN OR SUPPORTING SPOUSE FORM
If the applicant is or has been claimed as a tax dependent or has been substantially supported by
his/her parent or legal guardian, or spouse, this form must be completed. This information is necessary to
determine whether the applicant is eligible for in-state tuition rates as a dependent as set forth in Section
23-7.4 of the Code of Virginia
.
Please submit supporting documentation with this form. The application must be submitted prior to the
first day of classes for the semester or term. Requests for a change in Virginia domiciliary status will not
be accepted for a previous term.
NAME OF APPLICANT: _______________________ Social Security No. ______________
1. Name of Parent/Legal Guardian or Supporting Spouse
_____________________________________________________________________
You are applicant's (select one): parent guardian spouse
2. Current Address:
_______________________________________________________________________
_______________________________________________________________________
City State Zip Code
3. Permanent Address (if different):
______________________________________________________________________
St
reet, City, State, Zip Code
4. Telephone Number(s): Home ______________ Work ______________
5. Are you a citizen of the United States? YES [ ] NO [ ] If you are not a U.S. Citizen, list your
immigration status:
Type: ________________________________ Expiration Date: _________________
6. Was the applicant claimed as a dependent on your federal income tax return for the
previous tax year? YES [ ] NO [ ] Tax Year____
7. Do you provide over half of the applicant's financial support? YES [ ] NO [ ]
(e.g., tuition, books, housing, clothing, car payments, transportation, medical/dental care,
insurance, etc.) If YES, please provide a brief explanation: __________
_____________________________________________________________
8. If you are the applicant's guardian, is this by court decree? YES [ ] NO [ ] (attach copy)
9. Employment information:
Employer Hrs/Wk Address
From
M/D/Y
To
M/D/Y
Salary
JSRCC Form 11-0010 03/08
10. Were Virginia state income taxes withheld from your income during the past year?
YES [ ] NO [ ] If YES, Tax Beginning: ____________________
Month/ Day/ Year
11. Did you file a state income tax return to Virginia for the past two years:?
YES [ ] NO [ ] If YES, Tax Years: _________________________________________
If NO, to which state ________________________________________________
12. If you filed a Virginia state income tax return for the most recent tax year, did you file as a:
Resident [ ] Non-resident [ ] Part-year resident [ ] did not file [ ]
13. Are you registered to vote? YES [ ] NO [ ] If YES:
a. Where are registered to vote? City/County ___________________ State ______
14. Do you have a valid Virginia driver's license? YES [ ] NO [ ] If YES:
When was it first issued ? Month _______________ Year _______
15. Do you operate a motor vehicle? YES [ ] NO [ ] If YES:
a.
In which state was it registered? ______________________________________
b. Date of registration ____________________________________________________
16. Do you own real property (home) in Virginia? YES [ ] NO [ ] If YES:
a: County/City ______________________________________________
b. Purchase date: __________________________________________
17. If you have served in the military within the last five years, provide the following
information:
a.
Date of entering service _____________________________________________
b. Home of record____________________________________________________
c.
Current duty station ________________________________________________
e. State income tax withholding listed on LES_______________________________
18. Do you have an intention to remain in Virginia indefinitely? YES [ ] NO [ ]
To support your answer please discuss your reasons for wanting to stay in or leave Virginia:
* * * * *
I hereby certify that the information given is true and accurate. I also understand that if I provide erroneous
information in an attempt to evade payment of out-of-state fees, out-of-state fees will be charged to the student
for each semester/term attended.
Parent _____________________________________________ Date _______________
(or) Legal Guardian ___________________________________ Date _______________
(or) Supporting Spouse ________________________________ Date _______________
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APPLICATION FOR RE-CLASSIFICATION OF STUDENT'S DOMICILE STATUS (J Sargeant Reynolds Community College)

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Completed 27 July 2020

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