Revision 12/10/2018
This form is to be completed by students requesting reclassification of
their residence status for tuition purposes. Supporting documentation
must be attached. See the reverse for a list of acceptable documents;
additional documentation may be requested by staff if necessary.
Student ID:
Last First Middle
Phone: ________________________________ Term: Spring Summer Fall 20_____
Email: ____________________________________________ Please note, confidential messages will be sent only to Los Rios Gmail accounts.
Physical Presence
*If you will be 18 or younger on the first day of instruction, answer the Physical Presence and Intent questions below as they pertain to the
parent or guardian you most recently lived with in these sections; otherwise answer these sections as they pertain to you.
*Parent/Guardian Name:______________________________ *Relationship to Student:______________________________
Street City State/Country
On what date did your current stay in California begin? ________________
Have you resided at the address above continuously for the last two years?
Yes No*
*If you answered “No”, please list addresses for the past two years:
Street City State/Country Dates
Street City State/Country Dates
In the past year, have you:
Registered to vote or voted in a state other than California?
Petitioned for a divorce as a resident of another state?
Attended an out-of-state institution as a resident of that state?
Declared non-residence for California income tax purposes?
Yes No
Yes No
Yes No
Yes No
If you answered “yes” to any of the questions above, please give a brief explanation
(attach additional pages if necessary)
Do you possess a state driver’s license or identification card?
Do you have current motor vehicle registration?
Do you have an active California bank account?
Were you employed in California in the past year?
Yes No
Yes No
Yes No
Yes No
State: _______ Date Issued: ____________
State: _______ Date Issued: ____________
Date Opened: _______________________
Are you a U.S. Citizen?
Yes No*
*If you are not a U.S. Citizen, what is your immigration status? Documentation of status may be required
Permanent Resident Temporary Resident/Amnesty Refugee/Asylee Visa holder type: ________ Other
*Since entering the U.S., have you applied for Permanent Resident status, Asylum, Temporary
Protected Status, Family Unity Program, legalization or been granted a change of visa status?
Yes No
Status of Financial Independence*
(EC 68044, T5 54032)
*This section must only be completed if the student attended as a non-resident in
the preceding term. If you are reclassifying your first term, you may skip this section
This Year In the Prior Two Years
Did your parent(s) claim you as a dependent exemption for tax purposes?
Did your parent(s) give you more than $750 per year in financial assistance?
Did you live with your parent(s) for more than six weeks per year?
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
If you answered “yes” to any of the questions above, please list the place of residence of your parents:
Father: __________________________________________ Mother: _______________________________________________
Determination: _____Resident _____Non-Resident
Effective Term:______________
Reviewed by:___________ Date:____________
Supporting Documentation
Activity/Documentation Type
Date Issued/Begun
Documentation of visa and/or immigration status (non-U.S. citizens only; required in addition to two
documents verifying physical presence and intent)
Ownership of residential property in California or rental/lease agreements, or a signed affadavitt from
landlord showing continuous occupancy over the one year period prior to the start of the semester
Voter registration card or other proof of registration/voting within California
License from a California professional practice
Records of employment or maintaining a business in California; this may include, but is not limited to a
letter from employer on company letterhead showing date and location of employment
Indicated a California street address on tax forms (i.e. W-2, 540, 1040) or pay stubs
Payment of California personal income tax as a resident
California motor vehicle registration
Possession of a California driver’s license or California Department of Motor Vehicles (DMV)
identification card
Maintained a California address as the home of record in military records and on the Leave and
Earnings Statement (LES) while in the Armed Forces.
Verification of public assistance, rehabilitation, unemployment, or other California state services
including, but not limited to CalFRESH, MediCal, and Cash Aid
Petition for divorce as a California resident
Proof of jury duty service in a California court
Maintained active savings or checking accounts in California banks
(statement, checks or other documentation must show California physical address)
Other documentation may help clarify your residency. These include, but are not limited to:
Active resident membership in California service or social clubs
Car insurance, health insurance, or other insurance showing a permanent California address
Utility or Medical bills with a California address
Selective Service registration with a permanent California address
Receipts showing payment of non-resident tuition at an educational institution outside of California
Moving contract showing a California address
High School transcript or verification from California public library, including library card
Filed a lawsuit in California as a resident
Marriage license in California
Credit agreements with California business or credit card statements with a California address
Union membership in California local
California resident hunting or fishing license
Please list below other things you have done to support your request to be classified as a California resident. Physical presence
within California solely for educational purposes does not establish residency. (Attach additional pages if necessary.)
Do you qualify for any of the following categories? If so, please request the Special Consideration form for details.
Foster youth or former foster youth age 24 or less
Member of the military or dependent (child/spouse) on active duty or maintaining domicile in California or remaining in California after discharge
Full-time employee (or dependent) of a CA State agency assigned to work outside of California or employee of CCC, CSU, UC, or CA Maritime
In the process of being classified as a peace officer AND enrolled in police academy training courses in the Los Rios Community College District
Agricultural laborer for hire (or child of an agricultural laborer) who is seasonally employed
Graduate of a school in California operated by the United States Bureau of Indian Affairs
Self-supporting minor or minor under the care and control of individuals other than a parent/guardian for the past two years
I certify under penalty of perjury that the information submitted is true and correct. I agree to notify the Admissions & Records
Office if there is any change in my residence, immigration status, or other facts used in determining residency while I am a
student in this District. I understand that falsifying information could result in criminal charges for perjury and/or fraud; student
disciplinary action; and/or accumulated monetary damages resulting from non-payment of non-resident tuition. I further understand that all
documents submitted by me with this residency reclassification form become the property of the Los Rios Community College District.
Please attach at least two items that document your residency from the list below. The burden of proof is on the student to clearly
demonstrate both physical presence in California and intent to establish residence. All documents must be valid, legible, dated at
least one year prior to the start of the term and be identified with the student’s name and physical address.