Fill - Residence-Questionnaire

RESIDENCY CHECKLIST

Supporting documentation required with Residence Questionnaire. Students may apply for classification

through the 30th calendar day of the quarter.



Citizenship: If you are not a U.S. citizen, but you hold temporary or permanent resident immigration status, you must

provide your immigration document.

If you are not a permanent resident or U.S. citizen, you may be eligible for resident status if you have met one of the

following conditions:

 Resided in Washington for three (3) years immediately prior to receiving a high school diploma, and completed the

full senior year at a Washington high school, OR

 Completed the equivalent of a high school diploma and resided in Washington State for three (3) years immediately

before receiving the equivalent of the diploma, AND

 Continuously resided in the state since earning the high school diploma or its equivalent

If you are not a U.S. citizen and do not hold temporary or permanent resident immigration status, and you have met one of

the above conditions, submit the Washington Higher Education Residency Affidavit/Declaration/Certification form to

Enrollment Services along with an official high school transcript.





Financially Independent or Dependent: Submit the federal income tax form for the previous calendar year.

 Financially Independent Student

If the student is applying as a financially independent student, verification of financial independence must be

documented by submitting the student’s federal income tax return from the previous year. In addition, students 24

years of age and younger must submit their parent’s/legal guardian’s tax return for the previous year. From the

parent’s/guardian’s return, provide only those pages that list the dependents claimed and the signature of the

taxpayer. Disclosure of financial information is not required. If the student did not file taxes for the previous year,

complete the Residency Income and Expense Report and submit it with documentation supporting income.

 Financially Dependent Student

If the student is applying as a financially dependent student, verification of dependent status must be documented

by submitting the parent or legal guardian’s federal income tax return for the previous year. Provide only those

pages listing the dependents claimed and the signature of the taxpayer. Disclosure of financial information is not

required.

Establishment of domicile in Washington: Submit three original items from the list below. A photocopy of each item

will be made by Enrollment Services staff. Photocopies made by students are not acceptable. Mail received at an address

(bills, statements, etc.) is not an acceptable form of verification. Documents from the list below must be dated 12 months

prior to the first day of the quarter. Please note: financially independent students submit their own documentation, and

financially dependent students submit their parent/legal guardian’s documents. 

 Washington driver’s license or Washington ID card.

 Mortgage settlement document, lease/rental agreement, or rent receipts

 Washington motor vehicle registration (not title)

 Washington voter registration card.

 Evidence of full-time employment (employer statement noting hire date and full-time status)

 Evidence of checking or saving account in Washington state (that includes the date the account was opened)

 Address listed on selective service registration

 Membership in professional, business, civic or other organizations

 Receipt of benefits under public assistance programs

 Hunting or fishing license

 State in which a custodial parent has a child attending public school

Washington Residence Questionnaire

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

confidential in accordance with the Family Educational Rights and Privacy Act of 1974. Once a domicile is established in Washington, it must continue

for one year before you are eligible for resident tuition.

SECTION 1

Name (Last, First, MI)

Day Phone Number

FOR OFFICE USE ONLY

( )

Type

Address (Street, State, Zip)

Student ID Number

Status

DEP INDEP

E-mail Address

Birth City, State, Country

Birth Date

Age

Today's Date

1. Last high school attended _________________________________________ State _______ Year Graduated _____________

Effective Date

2. For what term are you now seeking residence classification? Year 20___ Fall Winter Spring Summer

If you have previously applied at this institution for a change in residence status, indicate: Term __________ Year __________

Resident Non-Resident

Class Standing: Undergraduate Graduate Professional School: _____________________________________

__________________________

Residence Classification Officer

3. At this Institution, you are 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 each of the last three terms and identify each term by session and year:

Credits ______ Term __________ Year __________ | Credits _______ Term __________ Year ___________ | Credits _______ Term __________ Year __________

4. Country of citizenship:

5a. Do you hold permanent or temporary resident immigration status? Yes No

If not USA, answer 5a, 5b and 5c.

5b. Do you hold "Refugee-Parolee," "Conditional Entrant" or PRUCOL status? Yes 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.

5c. Do you hold a visa classification of A, E, G, H-1, I, K, or L? Yes No

If yes to any of the above, you must present your Resident Alien Card, Form I-94, or other

documentation. (If you are not a citizen of the United States and do not hold permanent or temporary

resident immigration status, "Refugee-Parolee", "Conditional Entrant", PRUCOL status or an A, E, G, H-

1, I, K, or L visa, you cannot be classified as a resident.)

5. Have you received financial assistance from a state

governmental unit or agency during the past twelve months?

Yes No

If yes, indicate state, agency, type of assistance, disbursement dates, etc.

6. Will you be receiving state financial assistance during the next

twelve months? Yes 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 maintained a bona fide domicile in the State of

Washington for at least one year?

Yes No

If yes, your parent or legal guardian must complete SECTION 3 of this form, providing proof of his/her

Washington domicile and all requested supporting documentation. Verification of your dependent status must

be documented by submitting 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 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 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 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 of Student ____________________________________________________________________________________ Date ___________

2b. To further substantiate your financial Independence, you are required to submit appropriate documentation.

 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.

 Your W2 form filed for the previous calendar year.

 Other documented financial resources. Such other resources may include but are not limited to, the sale of personal or real property, trust fund, state or financial assistance, gifts, or earnings of the

spouse of a married student.

 If you are 24 or younger, provide the first page and the signature page of the state and federal tax return of your parents, legally appointed guardians, 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.

3. Are you on active duty military stationed in the state of Washington or the spouse or dependent of such a person? Yes No

4. Did you spend at least 75% of both your junior & senior years in a Washington state high school, and did you enroll in college within 6 months of leaving high school, and were your

parents/legal guardians domiciled in Washington for at least 1 year within the 5-year period before you graduated from high school? Yes No

Directions: Do not leave any questions blank. No decision can be made unless all questions are completed and all required documentation is submitted.

SECTION 3

1. This section is being completed and signed by:

Parent Legal Guardian Student

Date of your arrival in Washington :

Month: ________ Day _______ Year ______

Purpose of moving to Washington:

Date you took action to officially declare Washington as

your permanent, legal domicile:

Month: ________ Day _______ Year ______

2. List chronologically your employment and physical residence for the last two years giving exact information as requested below. If you were not employed, list your physical residence for

the last two years. Attach additional page if necessary.

DATES OF EMPLOYMENT

LOCATION

OCCUPATION

HOME ADDRESS

Mo. Day Yr.

City State

Employer Hrs/wk

Street City State

Note: You must provide proof of your physical presence in Washington the past 12 months (e.g. rent receipts, lease or home purchase agreements, cancelled rent checks,

letter from landlord, letter from employer, etc.).

3. If you were out of Washington during the last 12 months, give dates, and reasons for your absence:

DATES OF ABSENCE

LOCATION

PURPOSE OF ABSENCE

Mo. Day Yr.

City State

4. Have you ever

registered to vote?

Yes No

If yes, present

your current

voter's card.

If yes, list date, city and state for your last two registrations.

Date ____________ City __________________________ State ________ Date Voted ____________

5. Do you own or use any

motor vehicles, RV’s,

boats or mobile homes?

Yes No

If yes, give type of vehicle, license number, state and dates of registry. You must present your vehicle registration (not the title).

Type of vehicle ________________________ License Number __________________________ State __________ Date of Registry ___________

6. Do you have a valid

driver's license?

Yes No

If yes, present your

current driver's

license.

If yes, in what state:

_________________________

When did you first obtain a driver's license in that state?

Date ______________________________

Previous driver's

license?

Yes No

If yes, in what state:

_________________________

When did you first obtain a driver's license in that state?

Date ______________________________

7. Do you have a bank

account?

Yes No

If yes, present

documentation of date

you opened account.

If yes, since what date?

_________________________

Name of Bank _______________________ Branch _______________

City ________________________________ State ________________

8. Have you ever paid

in-state tuition at any

public institution of

higher education?

Yes No

If yes, date of last term __________________________________________

Name of Institution _____________________________________________

Dates Attended: From _____________________ To __________________

8a. Have you ever attended a Washington college/university for more than 6

hours per term? Yes No

If yes, where _________________________________________________

Dates attended From____________________ To ___________________

9. Are you a US Citizen?

Yes No

If no, present your Resident Alien Card, I-94 or other INS documentation.

10. List business or

professional licenses

(name & state of issue)

______________________________________________________________________________________________________________

Additional Comments:

STATEMENT OF INTENT

I certify that I have declared

Washington as my true, fixed,

and permanent place of

habitation.

CERTIFICATION

I certify under penalty of

perjury under the laws of the

State of Washington, RCW

9A.72.085 that the foregoing

and all supporting

documentation are true and

correct.

SIGNATURE OF PARENT (IF COMPLETING SECTION 3) _____________________________________ Date ___________

Parent Address (Street, City, State)

______________________________________________________________________________

Signature of Student ___________________________________________________________ Date ___________

AG Form #151 – Revised 1/15/02 – AG Approval 4/19/02. Revised by HECB 6/2009, AG approval 6/10/2009, effective 7/01/2009.

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