Fillable Border State Waiver Appl Application for Border State Waiver

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Border State Waiver Appl Application for Border State Waiver

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Albany State University
APPLICATION FOR BORDER STATE WAIVER
(Alabama, Florida, South Carolina & Tennessee ONLY)
TUITION DIFFERENTIAL WAIVER
Prior to submitting a Border State Residents out-of-state tuition waiver application, students are advised to review the University
System of Georgia Border State Residents out-of-state tuition waiver policy found in Section 7.3.4.1 of the Board of Regents
Policy Manual (www.usg.edu/policymanual). Please note that the Border State Residents out-of-state tuition waiver is available
to qualifying undergraduate students only. Documentation must be provided with application.
Section I – To be completed by the STUDENT
Name:
Student ID:
Address:
City:
State:
Zip:
Email:
Phone:
Term applying for waiver: Fall Spring Summer
Year:
Will you be attending as an Yes No
undergraduate student?
U.S. Citizen
U.S. Permanent Resident
Nonresident Alien
Other:
This waiver application is based on your present and permanent home (domicile) in the following eligible state (Alabama, Florida, South
Carolina) bordering Georgia:
State:
Will you have lived in the above state for at least 12 consecutive months immediately preceding the first day of classes for the term the
waiver is requested? Yes No
Have you graduated or will you graduate from a high school in the above state? Yes No
Have you ever lived outside of the above state above? Yes No
If Yes: The above has been your state of domicile since: (mm/yyyy)
Briefly describe your reason for moving to the above state:
Do you hold a current driver’s license/state-issued ID? Yes No State issued?
Do you own a motor vehicle? Yes No State registered?
Are you registered to vote? Yes No State registered?
Did you file a state income tax return for the most
recent tax year?
Yes No State filed?
Employment Information – Please list all employment for the past two years, including military service. Attach additional sheets if needed.
From To Employer City State # of hours worked per week
Students under the age of 24 must complete the following:
Do you have a parent or U.S. court-appointed legal guardian who has established and maintained domicile in an eligible state (Alabama,
Florida, South Carolina) bordering Georgia for at least 12 consecutive months immediately preceding the first day of classes for the term
the waiver is requested? Yes No State:
If Yes:
Name of the above individual:
Relationship: Parent U.S. court-appointed legal guardian
Has that individual ever lived outside of the above state? Yes No
If Yes:
They have maintained domicile in the above state since: (mm/yyyy)
Briefly describe their reason for moving to the above state:
Rev. 04/2019
Do they hold a current driver’s license/state-issued ID? Yes No State issued?
Do they own a motor vehicle? Yes No State registered?
Are they registered to vote? Yes No State registered?
Did they file a state income tax return for the most recent tax year? Yes No
If Yes:
State filed? Were you claimed as a dependent? Yes No
Did they file a federal income tax return for the most recent tax year? Yes No
If Yes: Were you claimed as a dependent? Yes No
Section II – STUDENT Oath and Affirmation/Notary Oath and Affirmation – Sign in the presence of a Notary
I understand that any material false statement made knowingly and willingly by me on this application, or any documents attached hereto
may, in accordance with O.C.G.A. 16-10-71, which provides that upon conviction, a person who knowingly commits the offense of false
swearing shall be punished by a fine of not more than $1,000 or by imprisonment for not less than one nor more than five years, or both,
subject me to prosecution in a court of law. Additionally, I further understand that any such false statement may subject me to immediate
dismissal from the institution.
Further, I certify that, to the best of my knowledge, the information submitted on this application is true and complete.
Student Signature Date
STATE OF ____________________________
COUNTY OF ____________________________
The foregoing instrument was acknowledged before me this __________ day of ___________________, 20__________,
By ___________________________________________ (individual applying for Tuition Waiver)
__________________________________________________
Signature of Notary Public
State of ____________________________________________
___________________________________________________
Name of Notary Typed, Printed or Stamped
Notary Seal
Personally known ____________ or produced Identification __________________
___________________________________________________________________
Type of Identification Produced
Rev. 04/2019
Section III –Notary Oath and Affirmation Documentation Requirements
LAWFUL PRESENCE IN THE UNITED STATES
Only those students verified to be lawfully present in the United States may be considered for an out-of-state tuition waiver. Waiver
applicants may be required to provide additional documentation to meet this requirement. One of the following must be submitted:
• A certified US Birth Certificate showing the student was born in the U.S. or a U.S. Territory. (A photocopy or faxed copy is not
acceptable)
• A U.S. Certificate of Naturalization (USCIS form N-550 or N-570)
• A U.S. Certificate of Citizenship (USCIS form N-560 or N-561)
• A U.S. Certificate of Birth Abroad issued by the Department of State (DS-1350) or a Consular Report of Birth Abroad (FS-240).
• A current military ID (service member only, not dependent)
• A current, valid permanent resident card (USCIS form I-151 or I-551). Must have copy of the front and back of the card.
• A current U.S. Passport
DOCUMENTATION OF WAIVER ELIGIBILITY
Additional documentation is also required to confirm domicile in the border state such as the following:
• Copy of lease agreement or warranty deed (dated 12+ months)
• Copy of driver’s license or state-issued ID
• Copy of vehicle registration
• Copy of state tax return filed for the most recent tax year
• Copy of federal tax return filed for the most recent tax year
• Copy of utility bills
By Email: (Preferred) By Mail:
Office of the Registrar
Atten: Tuition Classification Officer
registrar@asurams.edu
Subject: ATTN: Border State Waiver
Albany State University
2400 Gillionville Road
Albany, GA 31707
Forms and documentation should be submitted as a completed packet at least 4 weeks prior to classes beginning.
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Border State Waiver Appl Application for Border State Waiver

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Completed 1 November 2019

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