Yes No
3. If you have not lived in Virginia within the last two years,
have you ever lived in Virginia?
from: to:
4. Where have you been employed for the year prior to the term for which the applicant claims entitlement
Current (mm/yy-mm/yy):
Previous (mm/yy-mm/yy):
5. Will you have filed a tax return or paid income taxes to any state other than Virginia during the past year?
Yes No
If yes, explain:
6. For one year immediately prior to the term for which entitlement is sought, will you have:
a. filed a resident tax return or paid resident taxes to Virginia on all earned income?
Yes No
If no, explain:
b. been a registered voter in Virginia?
Month/Year registered:
Yes No
If no, are you a registered voter in any state?
Yes No
c. held a valid Virginia driver’s license? Month/Year issued:
Yes No
If no, are you licensed to drive in any state?
Indicate state:
Yes No
7. Do you own or operate a motor vehicle?
Yes No
If yes, has it been registered in Virginia during all of the past year?
Month/Year registered:
Yes No
If no, where has it been registered:
ANSWER QUESTION 8 ONLY IF YOU OR YOUR PARENT LIVE OUTSIDE VIRGINIA AND EMPLOYED FULL-TIME
IN VIGINIA.
8. Do you or your parent commute from a residence outside Virginia
to work full-time in Virginia and
pay
Virginia
non-resident inco
me
tax
on
all
taxable
income
earned
in
Virginia?
Yes No
If yes, provide a letter verifying Virginia employment, including dates of employment, location of employment, salary,
and
provide
a
copy
of
most
recent
non-resident Virginia
income tax
return. Date sent:
ANSWER QUESTION 9 ONLY IF YOU, YOUR PARENT, SPOUSE OR LEGAL GUARDIAN IS CURRENTLY IN THE
MILITARY, RETIRED OR A VETERAN.
9. Name of Military member, retiree or veteran: Relationship to Applicant:
a. Are resident Virginia income taxes being paid on all military income?
If yes, as of month/year:
Yes No
Provide a copy of a Leave and Earnings Statement. Date sent:
b. Where were you, your parent, legal guardian, or spouse stationed on that date:
c. Are
you, your parent, legal guardian, or spouse stationed to a permanent duty station in Virginia,
Washington, D.C., or any state contiguous to Virgin
ia?
Yes No
Provide a current copy of military orders. Date sent:
d.
Are you, your parent, legal guardian, or spouse currently residing in Virginia?
Yes No
If yes to both 9 (c) and (d), provide a copy of your current military orders reflecting Virginia assignment.
No
Yes
e.
Are you, your parent, legal guardian, or spouse retired or separated from military and living in Virginia?
If yes, provide military form DD214.
Yes
f.
Are you or your parent, legal guardian or spouse not currently living in Virginia but previously paid Virginia
income
tax on military earning
for a ten
year period
?
No
PLEASE USE THE SPACE BELOW TO EXPLAIN ANY OF YOUR RESPONSES:
By signing and submitting this form you,
your parent, legal guardian, individual acting in loco parentis, or spouse are
affirming that all the information provided is correct complete and true.
Enrolled students and applicants intending to enroll at the University of Virginia are subject to the Honor Code.
Applicant signature: Date:
Parent, legal guardian or individual acting in loco parentis or spouse signature:
Date:
Street:
City: State:
Zip:
Street:
City:
State:
Zip:
