Application for Reclassification of Residence for Tuition Purposes
A student seeking reclassification of residency for tuition purposes is responsible for sufficiently demonstrating
that he or she has met the requirements as listed in the University’s Residency Guidelines. To apply for
reclassification, attach this form to your personal statement and include all documentary evidence. This
application must be notarized.
Section I:
Personal Information
Name
Last First Middle Student ‘F’ Number
Date of Birth
Month/Day/Year
Date entered Fairmont State University
Permanent Address
Local Address
Street & Number (P.O. Box)
City State
Zip
Street & Number (P.O. Box)
City State Zip
Telephone Number ( )
United States Citizen: Yes No
If no, indicate: Type and Number of Visa Date of Issuance Port of Entry
Section II:
Please attach your
Personal Statement
that explains the reason(s) that you moved to the State of
West Virginia and why you believe you should be classified as a “resident student”.
Section III:
Please answer the following questions. Attach any documentary evidence that supports your
responses.
1.
List the permanent address(es) of your parents or legal guardians for the past
four
years.
Name (Relationship to Applicant)
Address
Dates
2.
List your address (es) for the past
four
years.
Address
Dates
3.
Where do you reside while attending Fairmont State University?
4.
Did you live in West Virginia prior to entering Fairmont State University? Yes No
If yes, when and for how long:
5.
List all institutions that you have attended for the last
four
years, including high schools.
Institution
Location (State) Dates Attended
6.
When do you consider that your West Virginia residency began?
7.
Do you own real property (i.e. land, home, etc.) in West Virginia? Yes No
8.
Are you presently married? Yes
No
If yes, does your spouse meet residency requirements as outlined in the University’s
guidelines? Yes No
9.
Are you currently registered to vote in West Virginia? Yes
No
If yes, when did you
register?
10.
Do you possess a valid photo identification (driver’s license or non-driver ID) issued by the State of West Virginia? Yes No
11.
Do you own a vehicle that is currently registered in West Virginia? Yes No
12.
List the names and addresses of all of your employers for the last
four
years.
Employer Address
Dates Employed
13.
Have you filed a West Virginia state personal income tax return? Yes
No
If yes, for which years
14.
Did your parent(s) or guardian(s) claim you as a dependent on their most recent tax return? Yes No
15.
What percentage of your tuition and living expenses is paid by your parent(s) and/or supporting person(s)? %
Section IV: U.S. Military Members and Veterans
(If you are not a veteran or current member of the military,
please leave this section blank.)
1.
Are you currently an active duty member of the U.S. military? Yes
No
If yes, please specify branch and current
assignment/location:
2.
Have you previously served on active duty for a period of at least two years? Yes
No
If yes, were you honorably discharged?
Yes
No
Please list your separation date from active duty status:
3.
Are you a current member of the West Virginia National Guard?
Yes
No
If yes, what month and year did you join?
4.
Are you currently a member of a reserve component of the U.S. military? Yes
No
If yes, what month and year did you
become a reservist?
5.
Have you been assigned a service-connected disability by the United States Department of Veteran Affairs? Yes No
If yes, please include documentation with this application.
Section V: Please provide legible copies of all documentation that verifies the information provided in this
application.
CERTIFICATION:
I do solemnly swear/affirm that the statement and evidence hereby presented in support of the foregoing
application are true and
correct; and, furthermore, certify that the permanent address listed in Section I above is my residence and that I
intend to remain at that address
indefinitely, and that I have more substantial connections with the State of West Virginia than with any other state.
(L.S.)
Signature of Applicant
SWORN TO AND SUBSCRIBED BEFORE ME THIS THE DAY OF , 20 .
My Commission Expires:
(
SEAL
)
Notary Public
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