PALM BEACH STATE COLLEGE
4200 Congress Avenue
Lake Worth, FL 33461-4796
Telephone: (561) 967-PBCC
Request for Florida Residency for Tuition Purposes
PLEASE PRINT
Student’s Name: ______________________________________ Student ID: ____________________
Name of Claimant ____________________________ Relationship to Student __________________
(The CLAIMANT is the person who is claiming Florida residency, e.g. , the applicant( if independent), parent, spouse or legal guardian. All of the questions below pertain to the claimant.)
Permanent Address __________________________________________________________________
City _____________________________ State ____ Zip ________ Telephone _______________
**COPIES OF ORIGINAL DOCUMENTATIONS MUST BE PROVIDED**
Date Claimant Began Establishing Legal Florida Residence and Domicile __________________
mm/dd/yy
All documentation must be dated one year prior to the first day of the term and must be received prior to the last day of
add/drop (Note* A minimum of 3 documents required for reclassification one must be a tier one document) FS1009.21.
Note: Additional information on residency can be found at http://www.palmbeachstate.edu/admissions/floridainstateinfo.pdf
Claimant’s Voter Registration: State:_____ County: ____________ Number: _________ Registration date ________
mm/dd/yy
Claimant’s Drivers License: State_____ Number: ______________________________ Issue date _______________
mm/dd/yy
Claimant’s Vehicle Registration: State_____ VIN Number: ___________________ Issue date _______________
mm/dd/yy
Citizenship:
U.S. Citizen Permanent Resident Alien Asylee or Refugee Alien Other _________
Resident Alien Number A__________________ Date Card Issued _______________________
(Copy of both sides of card required)
Do you own a home in Florida? _____ Yes ______ No (If Yes, provide proof of Homestead Exemption.)
Definitions:
Dependent A person for whom 50 percent or more of his/her support is provided by another as defined by the
Internal Revenue Service.
Independent A person who provides more than 50 percent of his/her support
.
Did your parent (s) claim you on your most recent income tax return? _____ Yes _____ No
(Students under the age of 24 must provide a copy of their parents’ and their most recent income tax return)
ADDITIONAL DOCUMENTATION MAY BE REQUESTED BY THE INSTITUTION
I do hereby swear or affirm that the above-named applicant meets all requirements indicated in the category checked above for classification as a Florida “resident for
tuition purposes.” I understand that a false statement in this affidavit will subject me to penalties for making a false statement pursuant to 837.06, Florida Statutes, and
that a false statement in this affidavit may subject the above-named student to the penalties for making a false or fraudulent statement.
___________________________________________ _______________________________________________ ___________________
Signature of Student in ink and of Claimant signature Date
OFFICE USE ONLY Action: ______Approved _______Disapproved Term: _____________
APPROVED BY: _________________________________________________ Date: _____________
