Fillable Oregon Health & Science University Instructions for Completing (Oregon Health Sciences University)

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Oregon Health & Science University Instructions for Completing (Oregon Health Sciences University)

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Oregon Health & Science University
Instructions for Completing Residence
Information Affidavit
Name (Print) Telephone Number ( )
Special Note: This completed form and all required documentation must be submitted by the last day to register for the term in which resident status is sought, but it is
highly recommended that all materials be submitted at least 30-45 days prior to the first day of the term.
A. IF YOU ARE FINANCIALLY INDEPENDENT:
1. Fill out the complete affidavit. Do not leave any blanks or questions unanswered.
2. Provide the following items:
a. Copies of rent receipts, lease, letter from landlord, canceled checks or home purchase agreement verifying residence
in Oregon for the 12 months prior to the quarter of application.
b. Copy of Oregon State vehicle registration, if you own a vehicle. If you use, but do not own a vehicle, it must also be
registered in the State of Oregon.
c. Copy of State of Oregon driver’s license, if you drive.
d. Any other documents you may have to show that you have established a “home” in Oregon (e.g., club/organization
membership cards, bank account).
e. For applicants under the age of 24, a copy of your parent’s (or legal custodian’s) state and federal tax return for the
most recent tax year (top portion listing exemptions and signature section only).
f. Documents verifying your financially independent status for the current calendar year and the prior calendar year
(including, but not limited to, tax return for the most recent tax year, W2 forms, financial aid award letters,
irrevocable trust funds, wage receipts).
g. If you are not a U.S. citizen, attach a copy of both sides of your Resident Alien Card, Form 1-94, Temporary
Resident Card or other verification of your status with the Immigration and Naturalization Service (INS).
3. Sign Section 2:2 A and have the affidavit notarized.
Decisions on residence status are based on documentary evidence submitted. Documents are part of your file and are not returned.
B. IF YOU ARE FINANCIALLY DEPENDENT (SUPPORTED BY A PARENT OR LEGAL CUSTODIAN BUT EXCLUDING
SPOUSE):
1. You fill out Section 1 and Section 2. If you are not a U.S. citizen, attach a copy of both sides of your Resident Alien Card or
Form 1-94.
2. Your parent or legal custodian completes Section 3 and provides documents verifying his or her status as a State of Oregon
resident and documents verifying your dependent status (See A 2. a-e above on this sheet). If your parent or legal custodian
is not a U.S. citizen, attach a copy of both sides of his or her Resident Alien Card, Form 1-94, Temporary Resident Card or
other verification of his or her status with the INS.
3. Your parent or legal custodian must have the affidavit notarized.
Decisions on residence status are based on documentary evidence submitted. Documents are part of your file and are not returned.
C. FEDERAL MILITARY PERSONNEL (United States Army, Navy, Air Force, Marine Corps, Coast Guard, National Guard, Air National Guard):
1. If you were a resident of the State of Oregon for a minimum of one year prior to leaving the state as a member of the military:
a. Fill out the complete affidavit.
b. Provide documented evidence that you resided in the state for a minimum of one year and that you are in the
military.
c. Provide copy of DD214 form.
2. If you are the spouse or dependent of a member of the military, you complete Sections 1 and 2, and your spouse, parent or
legal custodian completes Section 3. Your spouse, parent or legal custodian must provide the documented evidence that he
or she is a member of the armed services and is residing in the State of Oregon while assigned to active duty in this state.
3. If you are a member of the armed services and are residing in the State of Oregon while assigned to active duty in this state,
fill out the complete affidavit and provide documentation that confirms your current military assignment status.
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.
Section 1:
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
Year
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
Grad Date
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.
School
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
From To
School
From To
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
.)B.
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?
Discharge Date
0
Section 2
1. Are you applying for resident status as a dependent student whose parent or legal custodian has maintained a bona
fide domicile in the State of Oregon for the past year? Yes ( ) No ( ) If yes, your parent or legal
custodian must complete Section 3 of this form providing proof of his or her Oregon domicile and verification of
your dependent status must be documented by submitting a true and correct copy of your parent’s or legal
custodian’s state and federal income tax return (top portion listing exemptions and signature section only) for the
most recent calendar year. (The extent of the disclosure required concerning the parent’s or legal custodian’s state
and federal tax returns is limited to the number of dependents claimed and the signature of the taxpayer and shall
not require disclosure of financial information contained in the returns.)
2. Are you applying for resident status as a financially independent student? Yes ( ) No ( ) If yes, you must
complete the remainder of this form.
Student’s sworn statement: I have not and will not be claimed as an exemption for federal income tax purposes by any
person except myself or my spouse for the current calendar year and for the calendar year immediately prior to the year in
which this application is made; and I have not received and will not receive financial assistance in cash or in kind of an
amount equal to or greater than that which would qualify me to be claimed as an exemption for income tax purposes by
any person except myself or my spouse during the current year and for the calendar year immediately prior to the year in
which this application is made. Signature:
Date:
3. To substantiate your financial independence, you are required to submit appropriate documentation:
a. A true and correct copy of your state and federal income tax returns for the calendar year immediately
prior to the year in which this application is made. If you did not file a state or federal income tax return
because of minimal or no taxable income, documented information concerning the receipt of such
nontaxable income must be submitted.
b. A true and correct copy of your W2 form filed for the previous calendar year.
c. Other documented financial resources. Such other resources may include, but are not limited to, the sale
of personal or real property, inheritance, trust fund, state or financial assistance, gifts, loans, earnings or
savings of the spouse of a married student.
d. For applicants under the age of 24, a true and correct copy of the first page and signature page of the state
and federal tax returns of your parents, legal custodian, or person or persons having legal custody of you
for the calendar year immediately prior to the year in which this application is made. (The extent of the
disclosure required concerning the parent’s or legal custodian’s state and federal tax returns is limited to
the number of dependents claimed and the signature of the taxpayer and shall not require disclosure of
financial information contained in the returns.)
Section 3:
This section is being completed and signed by the ( )Student ( )Parent ( )Legal Custodian (Note: not to be
completed by spouse.) Do not leave any questions blank. No action will be taken nor can any decision be made unless all
questions are completed and all required documentary evidence is submitted.
1. Name(Last, Middle, First)
Phone
Address
2. Date of your arrival in Oregon to establish a permanent home: Month
Day Year
Purpose of moving to Oregon
You must attach proof of your presence in Oregon the past twelve months (e.g. copies of rent receipts, lease or
home purchase agreements, canceled rent checks, letters from landlords).
3. Do you own ( ) rent ( ) your housing? If not, explain how your housing is provided:
4. List chronologically your employment or physical presence for the last two years giving exact information as
requested below. Attach additional pages if necessary.
From
to City/State Employer/Activity hrs/week
From
to City/State Employer/Activity hrs/week
From
to City/State Employer/Activity hrs/week
From
to City/State Employer/Activity hrs/week
5. If you were out of Oregon during the last 12 months, give dates, and reasons for your absence.
From
to City/State Explanation
From
to City/State Explanation
From
to City/State Explanation
6.
Have you registered to vote? Yes ( ) No ( ) If yes, give date of issue
You must attach copy
of
your current voter’s regi
stration card.
7.
Do you own or use any motor vehicles, mobile homes, trailers or boats? Yes ( ) No ( ) If yes, give t
ype of
vehicle, license num
ber, state and dates of registry. You must attach a copy of vehicle registration (not
the title).
Have any of these vehicles previously been registered in another state? Yes ( ) No ( )
8. Do you have a driver’s license? Yes ( ) No ( ) If yes you must attach a copy of your driver
’s license.
9.
Do you have a checking account? Yes ( ) No ( ) If y
es, since what date?
Name of Financial Instituti
on City State
Do you have a savings account? Yes ( ) No ( ) If yes, since
what date?
Name of Financial Instituti
on
City State
10. List y
ears for which you file
d an Oregon Income Tax Return
11. Is income being withheld f
rom your earnings for Oregon income taxes? Yes ( ) No (
)
12. Do you i
ntend to file an Oregon Return this year? Yes ( ) No ( ) If no, why not
?
Additional C
omments (or attach other information/documentation) you think important:
NOT
ARIZATION
This affidavit cannot be acted upon until notarized for the person completing Section 3.
To be completed by a notary public after this form has been filled out.
State of:
County of:
The undersigned person, being first dul
y sworn, deposes and says: The foregoing statements are, and each of them is,
complete, true, and correct, and that Oregon Health & Science University may rely upon them.
Signature (in presence of Notary)
Subscribed and Sworn t
o before me this
day of , Year
(seal)
N
otary Public
M
y Commission expires:
When completed, return this form to the Registrar’s Office at the address listed below.
Persons interested in further information on or assistance with residency classification should contact:
Mickie Bush, Registrar
Oregon Health
& Science University, L-109
3181 SW Sam Jackson Park Rd.
Portland, OR 97201-3098
(503) 494-1277 or (800) 775-5460
E-mail: bushm@ohsu.edu
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Completed 23 July 2020

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