RESIDENCY AFFIDAVIT
ALL applicants, regardless of residency, must submit this form with the application for admission.
1. Name:
Last Name First Name Middle Initial Birth Name, if Different
2. LSAC Account Number: ____________________
3. Place of Birth:
4. U.S Citizen/permanent resident alien: Yes No
Non-resident Alien? Yes No Visa Type:
5. Permanent Mailing Address:
_____________________________________________________________ (good until) _______________
mm/dd/yyyy
6. Parent(s) Name and Address(es):
7. Parent(s) Telephone: (Day) (Evening)
8. Did or will your parents claim you as an income tax exemption in
2020? Yes No
2021? Yes No
9. Did either parent(s) or guardian(s) provide you with regular financial support for the past 12 months?
Yes Amount $ No
10. Applicant address(es) for the past two years (please include dates):
11. If you are married and your spouse is a Connecticut resident, please provide spouse’s name and address:
12. Did you attend and graduate from a Connecticut high school? Yes No
If so, please provide the name and graduation year:
13. Have you ever voted in the United States? Yes No
Please provide the state and year in which you last voted:
If no, please explain:
14. Do you hold a valid driver’s license or state identification? Yes No
State: License/ID number: Expires:
15. Did you file city, state and/or federal income tax returns within the past year? Yes No
Name each city(ies)/state(s) in which you filed:
Indicate address on your last federal income tax form:
16. Please check the classification that you believe is applicable to you:
Connecticut Resident
New England Student (applicants from RI or VT are eligible for in-state tuition plus 75%)
Out-of State (United States citizen living in any state other than CT, RI, VT)
Foreign
17. Additional information that may be helpful in determining your legal residence:
