Community Colleges of Spokane
RESIDENCE
QUESTIONNAIRE
CCS 4092 (Rev. 10/19) Marketing and Public Relations
Spokane Falls Community College
Residency Office MS 3011
3410 W Ft George Wright Dr
Spokane WA 99224-5288
509-533-3520
Spokane Community College
Residency Office MS 2151
1810 N Greene St
Spokane WA 99217-5399
509-533-7014
DIRECTIONS: Please print clearly and answer each question. Incomplete or illegible forms cannot be considered and will be returned. Falsification or
intentionally erroneous information is subject to perjury under the laws of the state of Washington, RCW 9A.72.085. All information will be kept confi-
dential in accordance with the Family Educational Rights and Privacy Act of 1974. Once a domicile is established in Washington it must continue for a
year before you are eligible for resident tuition. Complete form in full and attach required documentation. PLEASE PRINT.
SECTION 1
Name LAST FIRST MI Phone number
( )
FOR OFFICE USE ONLY
Type
Address
STREET CITY STATE ZIP ID number
Status
r DEP r INDEP
E-mail address Birth city, state, county Birth date Today’s date
1. Last high school attended
State Year graduated
2. For what term are you now seeking residence classification? Year 20 r Fall r Winter r Spring r Summer
If you have previously applied at this institution for a change in residence status, indicate: Term Year
Effective date
r Resident r Non-resident
Residence classification officer
3. Class standing:
r Undergraduate r Graduate r Professional School
4. At this institution you are or will be enrolled as a: r New student r Continuing student r Returning former student
If continuing or former student, give number of credit hours for which you were registered during each of the last three terms and identify each term by session and year:
Credit
Term Year / Credit Term Year / Credit Term Year
5. Country of citizenship:
If not U.S.A., answer 5a, 5b and 5c. If yes to 5a, 5b or 5c, attach a copy
of your U.S. Permanent Resident card, form I-94 or other immigration
documentation.
5b. Do you hold “Refugee—Parolee,” “Conditional Entrant” or PRUCOL status?
r Yes r No
NOTE: An immigrant refugee, and the spouse and dependent children of such refugee, may
be exempted from paying the nonresident tuition fees differential if the refugee (a) is on
parole status, (b) has received an immigrant visa or (c) has applied for U.S. citizenship.
5a. Do you hold permanent or temporary resident immigration status?
r Yes r No
5c. Do you hold a visa classification of A, E, G, I or K?
r Yes r No
6. Have you received financial assistance from a state or government unit or
agency during the past 12 months?
r Yes r No
If yes, indicate state, agency, type of assistance, disbursement dates, etc
7. Will you be receiving state financial assistance during the next 12 months?
r Yes r No
If yes, indicate state, agency, type of assistance, disbursement dates, etc.
SECTION 2
1. Are you applying for resident status as a
dependent student whose parent or
court-appointed legal guardian has main-
tained a bona fide domicile in the state
of Washington for at least one year?
r Yes r No
If yes, your parent or legal guardian must complete Section 3 of this form providing proof of his/her Wash-
ington domicile and all requested supporting documentation. Verification of your dependent status must
be documented by submitting a true and correct copy of your parent’s or legal guardian’s state and federal
income tax return for the most recent tax year. The extent of the disclosure required concerning the parent’s
or legal guardian’s state and federal tax returns is limited to the listing of dependents claimed and the sig-
nature 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?
r Yes r No
If yes, you must complete Section 3 of this form and provide all requested supporting documentation.
2a. STUDENT’S SWORN STATEMENT
I have not been 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 any form
directly or indirectly from parents, relatives, legal guardians or others for the current year and for the calendar year immediately prior to the year in which this
application is made.
Signature
Date
2b. To further substantiate your financial independence, you are required to submit appropriate documentation, including but not limited to:
• A true and correct copy of your state and federal income tax return 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.
• A true and correct copy of your W2 forms filed for the previous calendar year.
• Other documented financial resources, which may include but are not limited to, the sale of personal or real property, trust fund, state or financial assistance, gifts,
loans, or earnings of the spouse of a married student.
• If you are 24 or younger, provide a true and correct copy of the first and signature page of the state and federal tax return of your parents, legally appointed guard-
ians, or person or persons who have 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 guardian’s state and federal tax returns is limited to the listing of dependents claimed and the signature of the
taxpayer and shall not require disclosure of financial information contained in the returns.
