OFFICIAL ACTION: APPROVED SEMESTER DISAPPROVED
HELD FOR FURTHER ACTION
LACKS: Item 1
Item 2 Item 3 Item 4
App./
Deadline Lease, rent rec., etc. Voter’s reg. MS. license, bills, etc.
JACKSON STATE UNIVERSITY
14
00 John R. Lynch Street
Post Office Box 17330
Jackson, Mississippi 39217
Telephone 601-979-0928
Website: www.jsums.edu/admissions
MISSISSIPPI IN-STATE RESIDENCY STATUS CHANGE APPLICATION
Name _____________________________________________________________________
LAST FIRST MIDDLE
Sex: _____ Male
_____ Female
Social Security No. ___________________ Telephone No. (_____) _______________________
AREA CODE
Local Address
STREET NUMBER AND NAME
CITY STATE ZIP CODE
Date of Birth Place of Birth
MONTH DAY YEAR CITY STATE
Classification: Freshman Sophomore Junior Senior
Date of First Enrollment at Jackson State University
SEMESTER YEAR
If you have not reached the age of 21:
Are your Parents Legal Guardians
Spouse residents of the State of
Mississippi? Yes
No Are you choosing to enter a plea of Mississippi
In- State Residency based on their residency status? Yes
No
Please attach copies of your Own or your Parents or your Legal Guardians or your Spouse’s proof of
evidence material to support your Mississippi In-State Residency Status Change Application as outlined
in item 1-4 in the Residency Application Brochure.
WARNING: I CERTIFY THAT THE INFORMATION CONTAINED IN THIS APPLICATION IS
TRUE AND CORRECT. I UNDERSTAND THAT MISREPRESENTATION OR OMMISION OF
INFORMATION WILL CAUSE MY IN-STATE RESIDENCEY APPEAL TO BE REVOKED.
STUDENT’
S SIGNATURE DATE
If your in-state residency is approved, your financial aid will be
repackaged based on in-state cost
of attendance.
click to sign
signature
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