Fillable RESIDENCE QUESTIONNAIRE FOR RECLASSIFICATION Admissions & Records Office (Fresno City College)

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RESIDENCE QUESTIONNAIRE FOR RECLASSIFICATION Admissions & Records Office (Fresno City College)

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RESIDENCE QUESTIONNAIRE FOR RECLASSIFICATION
Admissions & Records Office
☐ ☐
☐
☐
____________ __
_____
___
☐ ☐
☐ ☐
☐ ☐
☐ ☐
Identification Information:
Student Name - Last, First, MI
Student ID #
Date of Birth
Phone
Mailing Address: Street
City, State, Zip Code
Office Use Only
Received:
Semester: ______________
Type: __________________
Residence Requirements: (T5 54020 & 54028)
Establishing residence requires BOTH physical presence in California AND o
bjective evidence that there is the intent to make
California your home for other than a temporary purpose. The one-year-and-one-day residence period does not begin until you are
present in California AND have demonstrated clear intent to become a California resident.
☐Yes ☐No Having read the above, I consider myself a
California resident for tuition purposes.
Physical Presence: (T5 54022)
You MUST have been physical
ly present in California for one year and one day on the first day of the term you wish to be declared a
resident for tuition purposes.
I arrived in California on: ______________________________
.
☐Yes ☐No I have left California since the above date for longer than a temporary absence.
☐Yes ☐No I am in California only for educational purposes.
Acts of Intent: (T5 54024)
Intent to make California your home for other than a temporary purpose may be demonstrated in many ways.
I have voted in another state.
Yes
No (If yes, provide date)
DATE
I have petitioned for lawsuit or divorce in another state.
Yes
No (If yes, provide date)
I
have attended an out-of-
state in
stitution as a resident of that
state.
Yes
No (If yes, provide date)
I
have declared non-resid
ence for California state income tax
purposes.
Yes
No (If yes, provide tax year)
I have owned or leased a home/apartment in California.
Yes
No (If yes, provide effective date)
I have voted in California.
Ye
s No (If yes, provide participation date)
I have a valid California driver license.
(If yes, enter #, issue, and expiration date)
Yes No
CADL#: Issued: Expires:
I have a valid California Motor Vehicle Registration.
Yes No (If yes, provide most recent issue date)
I have listed California as my home address on my most recent
Federal Income Tax.
Yes No (If yes, provide tax year)
I have filed California State Income Taxes.
Yes No (If yes, provide tax
year)
I have a
n active California bank account.
Yes No (If yes, provide dat
e opened)
Legal Statu
s: (T5 54002 & T5 54045[c])
☐ ☐
☐ ☐
☐
☐
☐ ☐
☐
☐
To establish California residency, you MUST be a U.S. citizen, permanent resident, an applicant for permanent resident status, or
possess a visa that does not preclude you from establishing domicile in the U. S.
Check the appropriate box:
☐U.S. Citizen
☐Refugee/Asylee (Provide I-94 Card): Number: ____________________ Issued: __________
___________________
☐Permanent Resident (Provide Permanent Resident Card)
Permanent Resident Card #:
_________
_____________
Resident Since: ___________________ Expires: ______________________
☐
Visa (Provide Visa Information):
Type of current Visa and #:
_________
______________
Issued: __________________________ Expires: _____________________
Financial Independence: (EC 68044 & T5 54032):
If yo
u are an adult student and your parents are not California residents, you MUST demonstrate financial independence, along
with physical presence AND intent. If your parents are not residents of California, you will be required to be financially independent in
order to be a resident for tuition purposes. Dependent children of California residents who do not meet the physical presence are
entitled to resident classification during the first year they are physically present in California; however, student must establish
California residency thereafter.
Will you or have yo
u been claimed as an exemption for state and federal tax purposes by your parent(s):
☐Yes ☐No In the current calendar year?
☐Yes ☐No In the preceding calendar year?
Will you or have you received more than $750 in financial assistance from your parent(s):
☐Yes ☐No In the current calendar year?
☐Yes ☐No In the preceding calendar year?
Will you or have you lived for more than six weeks in the home of your parent(s):
☐Yes ☐No In the current calendar year?
☐Yes ☐No In the preceding calendar year?
☐Yes ☐No I am under 19 years of age and I and my parent(s)/legal guardian have owned or rented property AND
lived in a home in California continuously for the past two years.
If you answered yes to any of the questions above, provide the current address of your parent(s).
If your parents are
divorced/separated, provide current address for both parents.
Parent(s) Name - Last, First, MI
( )
Mailing Address: Street
City, State, Zip Code
Parent(s) Name - Last, First, MI
Mailing Address: Street
City, State, Zip Code
Military Exemption:
☐Y
es ☐No I am an active member of the military stationed in CA. (Provide valid military ID and military orders to CA)
If yes, enter date
duty in CA began_________
________ AND Home of record ________________________
☐Yes ☐No I am a dependent of an active duty military member. (Provide valid military ID and military orders to CA)
If yes, enter date
duty in CA began_________
________ AND Home of record ________________________
☐Yes ☐No I have been discharged from active military duty within the last year. (Provide DD 214)
If yes, enter dis
charge date _________
______________ AND Home of record ________________________
Student Certification:
State Center Community College District requires two to three forms of proof to be submitted when requesting reclassification for California
residency in accordance with Education Code section 68040 et.seq. The burden of proof to clearly demonstrate both physical presence, intent
to establish residence in California, and when appropriate financial independence, lies with the student. Failure to provide requested
documentation will result in a non-resident classification.
I certify under penalty of perjury that the information on this application is correct. I understand that falsification or failure to report change in
residency may result in my dismissal.
Signature: ______________________________________________________________
Date:
_____________
Submit this questionnaire AND documentation to any State Center Community College District Admissions and Records Office.
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RESIDENCE QUESTIONNAIRE FOR RECLASSIFICATION Admissions & Records Office (Fresno City College)

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Completed 4 September 2020

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