VENTURA COUNTY COMMUNITY COLLEGE DISTRICT-ADMISSIONS & RECORDS
Military Dependent Residence Statement
(For use by military dependents claiming residency)
TO BE COMPLETED BY DEPENDENT STUDENT (Also complete student’s declaration at bottom of page)
Name _________________________________________________________________________ Social Security # ________________________________
Last First Middle Maiden
Date of Birth ___________________ Relationship to military sponsor ____________________________ Sex
Male Female
month/day/year
TO BE COMPLETED BY MILITARY SPONSOR
(must be on full-time active duty in California)
Name _________________________________________________________________________________________________________________________________
RateRank Last First Middle Maiden
Sex
Male Female Date of Birth ______________________ Date Entered Service ________________________ State ___________________
month/day/year month/day/year
Legal Residence for state income tax purposes:
______________________________________________________________________________ Effective Date _______________________________________
Street City State Zip
Home of Record as shown on military records:
______________________________________________________________________________ Effective Date ________________________________________
Street City State Zip
Date of military assignment to California ___________________________________________________________________________________________________
COMMANDING OFFICER’S/UNIT PERSONNEL OFFICER’S DECLARATION:
I hereby declare under penalty of perjury that the above statements are true and correct, and that the person named above has not been assigned to active duty in
California for educational purposes.
Signature ________________________________________________ Date ___________________________ Executed at __________________________________
Commanding Officer or Unit Personnel Officer month/day/year State of California
STUDENT’S DECLARATION:
I hereby declare under penalty of perjury that the above statements are true and correct. I understand that any misrepresentation will result in my immediate dismissal.
Signature ________________________________________________ Date ___________________________ Executed at __________________________________
Student State of California
