idency Requirement Waiver
This form is to be complete
d by an active-duty member of the U.S. Armed Forces and their legal dependents
stationed in Colorado on a permanent change-of-station basis or on a temporary assignment to duty in Colorado.
You must submit this form within 30 days of the first day of courses each semester.
You must provide a copy of your military or dependent ID card.
Please indicate the semester that you are requesting exemption: Spring Summer Fall
Student Status: Active-Duty Service Member (ADM) Dependent of a Milit
ary Member (DEP3)
If you are a dependent, name of Arm
ed Forces Members (Sponsor):
Armed Forces Affiliation: US Army USAF US Navy USMC USCG
I hereby certify that to the best of my knowledge the information furnished in this form is true and complete without the
intent of evasion or misrepresentation. I understand that if the above information submitted is found to be false or
misrepresented it is subject to penalty of perjury and is sufficient cause for dismissal.
Student Signature: _________________________________________________________ Date: ______________
EDUCATION OFFICE CERTIFICATION:
I certify that
is an member of the U.S. Armed active duty
is currently assigned to:
Permanent duty station (PCS) in Colorado at
Temporary assignment to duty (TDY) in Colorado at:
I certify that the above student is a legal dependent of this member.
Certification is valid for: Spring Summer Fall
Certifying Official Signature: ______________________________________________ Date: _____________
Records & Enrollment Services
Main Building, Room M2480
5900 S. Santa Fe Drive
Littleton, CO 80160