Oregon Health & Science University
Residence Information Affidavit
Special Note: You are requested to provide voluntarily your Social Security Number in order to assist OHSU in tracking your relations with OHSU and to
adequately coordinate files and programs which may relate to you. By providing your Social Security Number, you are consenting to these uses only. This
request is made pursuant to ORS 353.050 and 353.060. Provision of your Social Security Number and consent to its use is not required and if you choose not to
do so you will not be denied any right, benefit or privilege provided by law. OHSU will disclose your Social Security Number only if authorized by law.
Name (Print) Telephone Number ( )
Present Mailing Address
Permanent Mailing Address
Social Security Number (Optional, see above) Student Number
Age Date of Birth Place of Birth
1. When did your last continuous stay in Oregon begin? (month/day/year)
2. Have you previously applied at this institution for a change in residence status? Yes ( ) No ( )
3. For what term are you now seeking residence classification? Term
4. At this institution I am or will be enrolled as a: New Student ( ) Continuing Student ( ) Returning Former
Student ( )
If continuing or former student, give number of credit hours for which you were registered during the past year:
Hours/Term/Year Hours/Term/Year Hours/Term/Year Hours/Term/Year
5. Where and when did you graduate from high school? High School
6. Have you attended an Oregon institution(s) during the past year? Yes( ) No ( )
7. If yes to question 6, please indicate where and dates of attendance.
From To School From To
8. Have you attended an Oregon educational institution as a National Exchange, WICHE/WUE or Reciprocity
student? Yes ( ) No ( )
9. Have you ever paid in-state tuition at a public institution of higher education? Yes ( ) No ( ) if yes, date of
last term. School
10. Country of citizenship:
, if not USA, type of visa or other status
Do you hold permanent or temporary resident immigration status? Yes ( ) No ( )
Do you hold refugee or political asylum status? Yes ( ) Not ( )
If yes to any of above, you must attach a copy of both sides of Resident Alien Card or Form I-94, or other documentation.
11. Have you received financial assistance from a state or government unit or agency thereof during the past twelve
months? Yes ( ) No ( ) If yes, indicate state and/or agency and explain
Will you be receiving such assistance during the next twelve months? Yes ( ) No ( ) If yes,
indicate the state and/or agency, type of assistance, disbursement date and explain:
12. List totals of your financial resources for the past 12 months:
a. Support from Parent or legal custodian (all living expenses, travel, etc.) A.
b. Other support from outside sources (
including spouse, financial aid, gifts, personal loans, savings, financial
support from relatives or friends, inheritance, trusts, stocks bonds, VA benefits, etc
c. Self support (wages, salary, commissions, interest income, etc.) C.
The total of A, B, and C (
must meet or exceed the total in D). Total (A,B,C)
d. Total expenses (including all living expenses, travel, etc.) D.
13. Are you presently on extended active duty in federal uniformed military service (Army, Air Force, Navy, Marine,
Coast Guard, National Guard, Air National Guard)? Yes ( ) No ( )
14. If you answered yes in question 13, are you stationed and residing in Oregon? Yes ( ) No ( )
15. Are you the spouse or dependent child of a federal uniformed military person on active duty in Oregon?
16. From what state did you enter the military?