List periods of full-time employment and part-time employment, starting with the most current.
Employer _______________________ City ____________________ State_________ Hours per week:________ From: ____________ To: ____________
Month / Year Month / Year
Employer _______________________ City ____________________ State_________ Hours per week:________ From: ____________ To: ____________
Month / Year Month / Year
Employer _______________________ City ____________________ State_________ Hours per week:________ From: ____________ To: ____________
Month / Year Month / Year
Employer _______________________ City ____________________ State_________ Hours per week:________ From: ____________ To: ____________
Month / Year Month / Year
ATTACH ADDITIONAL SHEET IF SPACE PROVIDED IS INADEQUATE
Have you filed an income tax return with the Wisconsin Department of Revenue? yes no
If yes, specify the years: ___________ ___________ ___________
If you filed a tax form in another state, give state and last year filed __________________________________ Year_________
Are you registered to vote in Wisconsin? yes no Date you were first registered to vote in Wisconsin _______________________
Month / Year
If yes, where and when have you voted in Wisconsin? ____________________________________________ Month / Year___________________
If you have voted in another state, give state and date you last voted ________________________________ Month / Year___________________
From what state do you hold a valid driver's license? ___________________
Date first acquired ____________ Number __________________________
Month / Year
If you own a motor vehicle, in what state is it registered? _________________
Date first registered____________ Plate Number ______________________
Month / Year
Parents Data
Father's Full Name
Mother's Full Name
Permanent Home Address: Street
Permanent Home Address: Street
City State Zip Code
From
(Month / Year)
To
(Month/Year)
City State Zip Code
From
(Month / Year)
To
(Month/Year)
Previous Home Address: Street
Previous Home Address: Street
City State Zip Code
From
(Month / Year)
To
(Month/Year)
City State Zip Code
From
(Month / Year)
To
(Month/Year)
Is father a U.S. citizen? yes no
If no, visa type:
Where and when did father last register to vote?
Is mother a U.S. citizen? yes no
If no, visa type:
Where and when did mother last register to vote?
Has father filed Wisconsin state income taxes as a resident? yes no
If yes, specify the years: ______________ ______________ ______________
Has mother filed Wisconsin state income taxes as a resident? yes no
If yes, specify the years: _____________ _____________ ______________
Have you been claimed as a dependant on your father's yes no
federal income tax return during any of the past 12 months?
If no, when were you last claimed by your father?_________________________________
Have you been claimed as a dependant on your mother's yes no
federal income tax return during any of the past 12 months?
If no, when were you last claimed by your mother?__________________________________
If you relocated to Wisconsin from another state, what was the primary reason for relocating in Wisconsin?
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
_____________________________________________________________________________________________________________________________
Do you plan to maintain a permanent residence in Wisconsin during and after your period of education at a Wisconsin educational institution? yes no
PLEASE NOTE: IF THE QUESTIONS ON THIS FORM DO NOT ACCURATELY DEMONSTRATE YOUR RESIDENCY STATUS YOU MAY ATTACH A
STATEMENT EXPLAINING ANY UNUSUAL CIRCUMSTANCES.
I declare that the information I have provided on this form is, to the best of my knowledge and belief, true, correct and complete. In order to verify the information
reported, I agree that the State of Wisconsin Higher Educational Aids Board may request and obtain an official copy of my latest Wisconsin and/or federal
income tax return and to provide, if requested, any other documentation necessary to verify the information reported. I further agree to authorize the Board to
contact and obtain any necessary information from any educational institution, governmental agency or employer I have included on this form and to authorize
the Board to share any information with any Wisconsin educational institution.
_______________________________________________________________ _____________________________________________________
Signature of Student Date
