Fill - California Residence Questionnaire Admissions & Records Office (Allan Hancock College)

H________________________

Admissions & Records Office

California Residence Questionnaire

All students requesting residency reclassification must complete this form and supply all necessary dates, and provide required

support documentation.

1 of 3

September 2020

Office use only: Initials: ______

Semester/Year: ____________

Residence code: ____________

Identification Information: (Please print using blue or black ink)

Name: (Print full legal name. DO NOT use nicknames, initials or abbreviations)

_______________________________________ ____________________________________ _________

Last First Middle

Student’s Permanent Address:

__________________________________________ _____________________________ ___________________

Street City State and Zip Code

_______________________________________ _________________________________ _____

AHC Student ID Number Date of Birth Age

Phone number: ________________________________________

Residence Requirements: (Title 5, 54020 and 54028) Establishing residence requires both physical presence in

California and objective evidence that there is the intent to make California your home for other than a temporary

purpose. The one-year-and-a-day residence period does not begin until you are present in California AND have

demonstrated clear intent to become a California resident. If you are not a United States citizen or on a visa that allows you

to establish California residency, you must provide verification that you have applied for residency with the Bureau of Citizenship

and Immigration Services.

 Having read the above, I consider myself a California resident for tuition purposes. Yes No

Physical Presence: (Title 5, 54022) You must have been continuously physically present in California for one year and a

day prior to the first day of the term in which you wish to be declared a resident for tuition purposes.

 I arrived in California on (enter date): ___________________________ (mm/dd/yyyy)

 I have been away from California since the above date for longer than a temporary purpose: Yes No

 I am in California only for educational purposes: Yes No

Be prepared to provide primary and supplemental proof of residency as defined on AHC’s public website.

Please continue to page 2 of the California Residence Questionnaire

H________________________

Office of Admissions & Records

California Residence Questionnaire

All students requesting residency reclassification must complete this form and supply necessary dates.

2 of 3

September 2020

Office use only: Initials: ______

Semester/Year: ____________

Residence code: ____________

Acts of Intent: (Title 5, 54024) Intent to make California your home for other than a temporary purpose may be

demonstrated in many ways. Please respond to ALL of the following statements:

 I have voted in another state within the last year:

If yes, please list the state: ____________________

Yes No

 I have petitioned for divorce in another state within the last year:

If yes, please list the state: ____________________

Yes No

 I have attended an out-of-state educational institution as a resident of that state within the last year:

If yes, list the name and location of the educational institution:

Yes No

 I am 19 years of age or older and I have maintained a home in California (owned or rented)

AND lived in California continuously for the past two years:

Yes No

 I am under 19 years of age and I and my parent/legal guardian have owned or rented AND

lived in California continuously for the past two years:

Parent/Legal Guardian Name: _________________________________________

Residence Address: _________________________________________________

Yes No

Enter Date

an effective date

is required for

each yes answer

 I have owned or continuously rented or leased a home or apartment in California

for the last 12 months:

Yes No

 I am registered to vote in California.

If yes, when did you last vote:

Yes No

 I have a current California license for professional practice:

Yes No

 I have listed California as my home address on my Federal Income Tax Form:

Yes No

 I have filed a California State Income Tax Return (as a RESIDENT):

Yes No

 I have a valid California Resident Motor Vehicle Registration:

Yes No

 I have a valid California driver’s license:

Yes No

 I have a valid California state identification card:

Yes No

 I have had an active California bank account:

Yes No

 I petitioned for divorce in California:

Yes No

 I have a valid driver’s license (if yes, please provide a copy)

 When was it issued? Enter mm/dd/yyyy _____________________________

 When does it expire? Enter mm/dd/yyyy ____________________________

 In which state was it issued? _____________________

Yes No

 Does your parent file state and/or federal income tax returns?

If yes, are you claimed as a dependent? (copies of tax returns required)

Yes No

Please continue to page 3 of the California Residence Questionnaire

H________________________

Office of Admissions & Records

California Residence Questionnaire

All students requesting residency reclassification must complete this form and supply necessary dates.

3 of 3

September 2020

Office use only: Initials: ______

Semester/Year: ____________

Residence code: ____________

Enter Date

an effective date

is required for

each yes answer

 Have you or will you apply for federal financial aid (FAFSA; PELL) for the academic

year in which you are applying for residency?

 If yes, what state did you list as your permanent home? ______________________

Yes No

 Are you an active member of the military?

If yes, when did your tour in California begin?

What is your state of legal residence on military records? ____________________

Yes No

 Are you a dependent of an active duty military person?

If yes, when did your sponsor’s tour in California begin? Enter mm/dd/yyyy

What is your sponsor’s legal home on military records? _____________________

Yes No

 If you are a dependent of an active duty military person, are you claimed as an

exemption for federal and state income tax purposes by your sponsor?

What state is listed as your legal home on last year’s Federal Income Tax forms?

_________________________

In what state did you file last year’s STATE tax returns? ______________________

Yes No

 Have you been discharged from active military duty within the last year?

If yes, what was your discharge date? Enter mm/dd/yyyy

What was your state of legal residence on military records? ___________

(Please provide us with a copy of your DD-214)

Yes No

 Are you a legal dependent of a parent who earns his or her livelihood in agricultural

labor?

If yes, has the parent performed such labor in California for at least two months of

each of the last two years, and resides in the Allan Hancock College Community

College District?

Yes No

 Do you earn your livelihood primarily in agricultural labor?

If yes, have you performed such labor in California for at least two months of each of

the last two years, and reside in the Allan Hancock College Community College

District?

Do you file state and/or federal income tax returns? (copies of tax returns required)

Yes No

Student Certification:

You may be required to supply additional information to determine your residency status in accordance with the California

Education Code, Sections 68040 et seq. The burden of proof to clearly demonstrate both physical presence in California and

intent to establish California residence lies with the student. Failure to provide requested residency information will result in a

determination of non-resident.

I certify under penalty of perjury that the information on this application is correct and I understand that falsification or failure to report

change in residency may result in my dismissal from the college.

_____________________________________________ ____________________

Student Signature (mandatory) Date

This form may be submitted in person to the Admissions and Records office or by email to: jcabanas@hancockcollege.edu

click to sign

signature

click to edit

Download
Save PDF to desktop

Email
Email completed PDF

Send for Signing
Email for others to sign

Print
Print document

NAME

California Residence Questionnaire Admissions & Records Office (Allan Hancock College)

View Audit Log
Print With Audit Log
Duplicate Document

Fill Online, Printable, Fillable, Blank California Residence Questionnaire Admissions & Records Office (Allan Hancock College) Form

Related forms

Fillable California Residence Questionnaire Admissions & Records Office (Allan Hancock College)

Fill Online, Printable, Fillable, Blank California Residence Questionnaire Admissions & Records Office (Allan Hancock College) Form

Related forms

First 20 documents completely FREE!