Massachusetts Community Colleges
In-State Tuition Eligibility Form
For ocial use. Do not write in this box.
I have reviewed the above information in order to determine applicant’s eligibility to receive the in-state tuition rate.
Based on my review I have determined this applicant:
_____ IS eligible for the in-state tuition rate.
_____ IS NOT eligible for the in-state tuition rate.
_____ I am unable to make a determination at this time. The following additional information has been requested from the applicant:
Authorized College Personnel Signature Date
Signature of Applicant Date
I certify that all above information is true.
Signature of Parent Date
If applicant is under 18 years of age.
_____ I HAVE BEEN A MASSACHUSETTS RESIDENT FOR SIX CONTINUOUS MONTHS AND INTEND TO REMAIN HERE.
As proof of my intent to remain in Massachusetts, I possess at least two of the following documents, which I shall present to the institution upon request. These documents*
are dated within one year of the start date of the academic semester for which I seek to enroll (except possibly for my high school diploma). The institution reserves the right
to make any additional inquiries regarding the applicant’s status and to require submission of any additional documentation it deems necessary. Please check-o those
documents you possess as proof of your intent to remain in Massachusetts.
VALID DRIVER’S LICENSE UTILITY BILLS* EMPLOYMENT PAY STUB*
VALID CAR REGISTRATION VOTER REGISTRATION* STATE/FEDERAL TAX RETURNS*
MASS. HIGH SCHOOL DIPLOMA SIGNED LEASE OR RENT RECEIPT* MILITARY HOME OF RECORD*
RECORD OF PARENTS’ RESIDENCY FOR UNEMANCIPATED PERSON* OTHER
_____ I AM AN ELIGIBLE PARTICIPANT IN THE NEW ENGLAND BOARD OF HIGHER EDUCATION’S REGIONAL STUDENT PROGRAM.
_____ I AM A MEMBER OF THE ARMED FORCES (OR SPOUSE OR UNEMANCIPATED CHILD) ON ACTIVE DUTY IN MASSACHUSETTS.
7/1
6/19
STUDENT ID #:
LAST NAME
MIDDLE NAME
ADDRESS
SOCIAL SECURITY #: DATE OF BIRTH
CITY
Optional, but required if
seeking financial aid or tax credit.
STATE ZIP
ANY PREVIOUS LAST NAMES
FIRST NAME
Are you a U.S. Citizen? Yes No
If not, please complete the following.
ARE YOU A PERMANENT RESIDENT? YES NO IF YES, LIST ALIEN REGISTRATION NUMBER:
IF YOU ARE NOT A U.S. CITIZEN OR PERMANENT RESIDENT, PLEASE STATE YOUR VISA OR IMMIGRATION STATUS IN DETAIL:
Please check the in-state or reduced tuition eligibility category that applies to you:
Certification of Information
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary action up to
dismissal, with no right of appeal or to a tuition refund.
