Fillable Residency Application (University of Kentucky)

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Residency Application (University of Kentucky)

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  • 36 check-boxes
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OATH AND AUTHORIZATION FOR USE OF RECORDS
To the student: This statement must be notarized before returning. Do not sign this statement until you are directed to do so by a
Notary.
State of _____________________________
County of ____________________________
The undersigned person, being first duly sworn, states as follows: That the foregoing statements and all supporting documents are, and
each of them is, true and correct. That any and all of the documents maintained by this institution may be released to the Committee or
its designated representative to be used by that Committee or its representative in the determination of my status as a resident or
nonresident of the Commonwealth of Kentucky for admission and tuition assessment purposes.
__________________________________________________
Signature of Applicant
Subscribed and sworn to before me this ____________ day of ____________________, _________ (year).
__________________________________________________
Notary Public
County of __________________________________________________
My commission expires __________________________________________________.
DOCUMENTATION IS REQUIRED
All items marked with one asterisk (*) must have accompanying documentation. Applications without substantial and
sufficient documentation will not be processed and will be considered incomplete.
Initial all items marked with two asterisks (**) to indicate whether documentation is provided. If not applicable or not
provided, initial next to “No.”
For Office Use
Student
Decision:
Date application initially filed:
Date:
Date application completed:
Case/File I.D.:
Term for which application applies:
Signed:
W O S
click to sign
signature
click to edit
Yes No
Yes No
I. Basis for Application
Check one (required):
Independent person demonstrating domicile and residency in Kentucky.
Dependent person seeking residency and domicile of resident parent(s) or legal guardian.
Seeking Kentucky residency status provided under Section 7 of 13 KAR 2:045 (Duty in the armed forces).
Beneficiary of a Kentucky Educational Savings Plan Trust.
II. Enrollment Information
1. Have you previously filed an application for determination of residency status?
If yes, for what term? _________________
2. Indicate the term and year (one term only) for which this application should be considered:
Fall 20____
Spring 20____
First Summer Session 20____
Second Summer Session 20____
3. Are you currently enrolled in a Kentucky college or university?
If no, for which term do you plan to enroll? Term__________________ Year_____________
If yes, which institution? __________________________________
4. Check one: Undergraduate Graduate Law Public Health
Medicine Dentistry Pharmacy
How many credit hours are you currently taking? ____________, or will be taking? ____________
III. Personal Information
1. Name: ______________________________________________________________________________________________
Last First Middle Maiden, Jr, II, etc.
2. Social Security Number: ___________ - ____________ - ____________
3. Birthdate: Month ____________ Day _______ Year ____________
4. State and Country of Birth: State __________________ Country __________________________
5. Permanent Address ____________________________________________________________________________________
Number Street
____________________________________________________________________________________________________
City County State Zip
**Lease/Deed Provided: Yes _____ No _____
*
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Yes No
Yes No
Yes No
Yes No
Yes ; who? ____________________ No
6. Present Address _______________________________________________________________________________________
Number Street
____________________________________________________________________________________________________
City County State Zip
**
Lease/Deed Provided: Yes _____ No _____
7. UK Assigned E-mail Address: ________________________________________________
8. To which address should this decision be sent? (Decisions will be sent via email unless indicated otherwise.)
Permanent Present E-mail
9. Phone Number (including area code):
Home (______) ______ - __________ Work (______) ______ - __________
IV. Determination of Dependent/Independent Status
1. Did you file a federal or state income tax return as an independent person claiming yourself as an exemption?
Federal Income Tax Forms State Income Tax Forms
If yes, for what most recent year? _______________
**Federal Income Tax Return Provided: Yes _____ No _____
**State Income Tax Return Provided: Yes _____ No _____
2. Did either of your parents claim you as a dependent for the tax year preceding the date of this application on federal or state
income tax forms?
Federal Income Tax Forms State Income Tax Forms
If no, when did either of your parents last claim you as an exemption on a:
Federal income tax form? _______________ State income tax form? _______________
** Federal Income Tax Return Provided: Yes _____ No _____
** State Income Tax Return Provided: Yes _____ No _____
3. Does any other person currently claim you as a dependent or exemption for federal or state tax purposes?
**If yes, tax return provided: Yes _____ No _____
4. Indicate the present means of your financial support and sustenance.
**Monthly Budget Provided (Detailed list of monthly expenses, income, loans, etc.): Yes _____ No _____
ANNUAL SUPPORT
Work: $____________ Spouse: $____________ Parent: $____________ Other Persons: $_____
Scholarships: $___________ Grants: $____________ Assistantships: $__________ Loans: $____________
Agency: $____________ Financial
Institutions: $____________
Trusts: $____________ Other: $____________
*
*
*
*
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Yes No
Yes No
Yes No
For other, please explain: _______________________________________________________________________________
____________________________________________________________________________________________________
When did your parent(s)/legal guardian last provide you with any of the above-listed support? Month _______ Year_______
Please provide any additional information not specifically requested on the list of supporting documents but which may
explain the nature of the financial support available to you.
____________________________________________________________________________________________________
V. Information in Support of Domicile
1. When did your present (i.e. your latest) stay in Kentucky begin? Date:______________________
2. What was your primary reason for coming to Kentucky? _______________________________________________________
What is your primary reason for your being in Kentucky at this time?______________________________________
3. What family do you have presently living in Kentucky? _______________________________________________________
4. Are you a citizen of the United States? (If yes, proceed to questions number 5.)
If you are not a citizen of the USA, please list country of citizenship._____________________________________________
*Are you a political refugee?
*Do you have a permanent visa?
If yes, when did you receive approval for your status from the Office of Immigration and Naturalization Services?
Month _______ Year _______
*If you have a permanent visa card, please give the card number, date issued, and date of expiration.
Card Number: _______________________ Date Issued: _______________________ Expiration Date: _________________
*What type of Visa do you hold? _____________________ What is the status of your passport? ______________________
** Permanent Visa Provided: Yes _____ No _____
** Visa Card Provided: Yes _____ No _____
5. List places where you have lived for at least the past five years (beginning with your most recent address).
From To Place of Residence
Mo/Yr Mo/Yr Number/Street City State
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Yes No
Yes No
Yes No
Yes No
Yes No
6. List the name of your high school, state located, and date of graduation or GED:
School Name: _________________________________________________________________________
City: _______________________________ State: _______________ Year of Graduation: ____________
7. List educational institution(s) attended after high school (beginning with most recent institution):
Residency for
Dates Attended Tuition Purposes
Educational City/ From To Full/Part In-State/
Institution State Mo/Yr Mo/Yr Time Out-of-State
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
8. Are you receiving benefits from the Kentucky Educational Savings Plan, covered under a vested participation agreement?
9. Have you lived in Kentucky while enrolled in 6 or fewer hours for the 12 months preceding the first day of classes of the
term for which you are applying?
**Unofficial Transcript Provided: Yes _____ No _____
10. Did you file a Kentucky state income tax return for either or both of the past two years?
If yes, please indicate year(s). _________, _________
**Kentucky Tax Return Provided: Yes _____ No _____
11. Have you accepted a full-time employment or transfer to an employer in Kentucky?
Have you accepted a full-time employment or transfer to an employer in an area contiguous to Kentucky while maintaining
domicile in KY?
** Job Offer/Transfer Letter Provided: Yes _____ No _____
12. List your employers for the past five years (beginning with the most recent):
Dates
From To Average Number
Mo/Yr Mo/Yr Employer City/State Hrs/Wk Wk/Yr
____________________________________________________________________________________________________
____________________________________________________________________________________________________
The Kentucky Educational Savings Plan was established as an investment program for beneficiaries to defray the cost of higher
education in the Commonwealth of Kentucky. 13 KAR 2:045 provides for beneficiaries of this program to be granted residency
status for tuition purposes, if they meet the criteria set forth in Section 9.
*
*
*
*
*
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No; owner’s name_________________________
Yes; where_______________________ No
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
13. Do you have licensing or certification for professional or occupational purposes in Kentucky?
If yes, what type? ______________________________________________________________________________________
**Professional License/Certificate Provided: Yes _____ No _____
14. Have you paid the following taxes in Kentucky during the 12 months preceding the first day of classes of the term for which
you are seeking determination of residency status?
*Occupational *Real Property
** Kentucky Tax Provided: Yes _____ No _____ **Property Tax Provided: Yes _____ No _____
15. What real property do you, your parents, legal guardian, or spouse own and in which state is it located? Indicate which
property is used by you as a residence.
Property Location of Property Used by Student for Residency Dates Used as Residence
Owned By Owned Residency (Y/N) From(Mo/Yr) To(Mo/Yr)
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
16. Do you have a lease for 12 months or more for noncollegiate housing in Kentucky?
**Lease Provided: Yes_____ No _____
17. Do you operate a motorized vehicle in the state of Kentucky?
If yes, is this vehicle registered in your name?
State in which vehicle is registered __________________________ Vehicle License Number ________________________
**Car Registration Provided: Yes _____ No _____
If you do not operate a vehicle, what is your means of transportation? ____________________________________________
Number of miles you travel to campus ________________ Number of miles you travel to work _______________________
18. Driver’s License Number: __________________________ State in which license was issued: _________________________
**Driver’s License Provided: Yes _____ No _____
19. Where do you live during school vacation periods? ___________________________________________________________
20. Are you currently registered to vote?
**Voter Registration Provided: Yes _____ No _____
*
*
*
*
*
*
*
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
■
Yes No
Yes No (specify) ________________________
Yes No
21. Are you now, or have you been, in the military?
When did you become an active member of the military? Month _____________ Year ___________
List active military service (exclusion of time spent in the Reserves)
From: (Mo/Yr) _________________ to: (Mo/Yr) _______________________
Was Kentucky your state of residency when inducted?
If no, what date, if any, did address change to Kentucky? Month ______________________ Year _____________________
Did you maintain, or are you maintaining, Kentucky as your legal residence while in the service?
Date of Discharge: Month _______________________ Year______________
**L.E.S./Orders Provided: Yes _____ No _____
VI. Supporting Information
1. Parents
Father’s Name: _____________________________________________________
*Father’s Permanent Address: ____________________________________________________________________________
City ________________________________________________ State _____________________________
Father’s Mailing Address: _______________________________________________________________________________
City ________________________________________________ State _____________________________
Father’s Telephone Number: (______) ______ - __________
How many years (continuously) has your father been living in Kentucky, if at all? ____________
*Provide the following information on your father’s current employer:
Name: _______________________________________________________________________________________
Address: _____________________________________________________________________________________
Phone: (______) ______ - __________
Date Current Employment Began: Month _________________ Year __________________
*Father’s Visa Type, if applicable: ____________________________________
**Father’s Lease/Deed Provided: Yes _____ No _____
**Father’s Letter from Employer Provided: Yes _____ No _____
Section VI, Supporting Information, relates to the basis for your request for determination of residency status, and you should
complete all relevant items in this section. Completion is required if your relationship to any individual mentioned is relevant to
residency in Kentucky; however, some of this information may still be relevant if you are filing as an independent person in your
own right.
*
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
**Father’s Visa Provided: Yes _____ No _____
____________________________________________________________________________________________________________
Mother’s Name: _____________________________________________________
*Mother’s Permanent Address: ___________________________________________________________________________
City ________________________________________________ State _____________________________
Mother’s Mailing Address: ______________________________________________________________________________
City ________________________________________________ State _____________________________
Mother’s Telephone Number: (______) ______ - __________
How many years (continuously) has your mother been living in Kentucky, if at all? ____________
*Provide the following information on your mother’s current employer:
Name: _______________________________________________________________________________________
Address: _____________________________________________________________________________________
Phone: (______) ______ - __________
Date Current Employment Began: Month _________________ Year __________________
*Mother’s Visa Type, if applicable: ____________________________________
**Mother’s Lease/Deed Provided: Yes _____ No _____
**Mother’s Letter from Employer Provided: Yes _____ No _____
**Mother’s Visa Provided: Yes _____ No _____
____________________________________________________________________________________________________________
2. Legal Guardian (Complete if applicable)
Legal Guardian’s Name: _____________________________________________________
*Legal Guardian’s Permanent Address: ____________________________________________________________________
City ________________________________________________ State _____________________________
Legal Guardian’s Mailing Address: _______________________________________________________________________
City ________________________________________________ State _____________________________
Legal Guardian’s Telephone Number: (______) ______ - __________
How many years (continuously) has your legal guardian been living in Kentucky, if at all? ____________
*Provide the following information on your legal guardian’s current employer:
Name: _______________________________________________________________________________________
Address: _____________________________________________________________________________________
Phone: (______) ______ - __________
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Date Current Employment Began: Month _________________ Year __________________
* Legal Guardian’s Visa Type, if applicable: ____________________________________
** Legal Guardian’s Lease/Deed Provided: Yes _____ No _____
** Legal Guardian’s Letter from Employer Provided: Yes _____ No _____
** Legal Guardian’s Visa Provided: Yes _____ No _____
** Record of Court-Appointed Guardianship Provided: Yes _____ No _____
3. Spouse
Name of Spouse: ______________________________________________________________________________________
*Date of Marriage: Month _____________ Year __________
** Marriage License/Certificate Provided: Yes _____ No _____
What family does your spouse have presently living in Kentucky? _______________________________________________
____________________________________________________________________________________________________
List spouse’s place(s) of residence for at least the past 5 years (beginning with the most recent address):
Dates
From To Place of Residence
Mo/Yr Mo/Yr Number/Street City State
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
__________________________________________________________________________________________________
List the name of spouse’s high school, state located, and date of graduation of GED.
School Name: ________________________________________________________________________________________
City: _______________________________ State: _______________ Date of Graduation or GED: ____________________
List educational institution(s) attended by spouse since high school (beginning with most recent institution):
Residency for
Dates Attended Tuition Purposes
Educational City/ From To Full/Part In-State/
Institution State Mo/Yr Mo/Yr Time Out-of-State
____________________________________________________________________________________________________
____________________________________________________________________________________________________
Marriage to a Kentucky resident may be a factor in determination of your residency status Section 10 (2)(k). If your spouse has
fulfilled requirements for residency and domicile in Kentucky, it is very important that this section be completed and accompanied
by supporting documentation. If you are filing this application as an independent person in your own right, several items in this
part of the affidavit may still be supportive of your own claim to residency and domicile.
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Yes No
Yes No
Yes No
Yes No
Yes No
____________________________________________________________________________________________________
____________________________________________________________________________________________________
List spouse’s employers for the past five years (beginning with the most recent):
Dates
From To Average Number
Mo/Yr Mo/Yr Employer City/State Hrs/Wk Wk/Yr
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
____________________________________________________________________________________________________
*Did your spouse file a Kentucky state income tax return for either or both of the past two years?
If yes, please indicate years. _________________________ __________________________
** State Income Tax Return Provided: Yes _____ No _____
*Did your spouse file a federal or state income tax return as an independent person claiming you as an exemption?
Federal Income Tax Forms State Income Tax Forms
If yes, for what most recent year? ________________________
** Federal Income Tax Return Provided: Yes _____ No _____
** State Income Tax Return Provided: Yes _____ No _____
*Did either of your spouse’s parents claim your spouse as a dependent for the tax year preceding the date of this application
on federal or state income tax forms?
Federal Income Tax Forms State Income Tax Forms
If no, when did either of your spouse’s parents last claim your spouse as an exemption on a:
Federal income tax form? _______________________ State income tax form? ____________________________
** Federal Income Tax Return Provided: Yes _____ No _____
** State Income Tax Return Provided: Yes _____ No _____
*Indicate your spouse’s present means of financial support and sustenance.
ANNUAL SUPPORT
Work: $____________ Spouse: $____________ Parent: $____________ Other Persons: $_____
Scholarships: $___________ Grants: $____________ Assistantships: $__________ Loans: $____________
Agency: $____________ Financial
Institutions: $___________
Trusts: $____________ Other: $____________
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
Yes No (specify) ________________________
Yes No
Yes No
For other, please explain: _______________________________________________________________________________
____________________________________________________________________________________________________
When did your spouse’s parent(s)/legal guardian last provide you with any of the above-listed support?
Month _______ Year_______
Please provide any additional information not specifically requested on the list of supporting documents but which may
explain the nature of the financial support available to your spouse.
____________________________________________________________________________________________________
*Spouse’s Visa Type, if applicable: ________________________________
**Spouse’s Visa Provided: Yes _____ No _____
4. Military – Indicate which of the following individuals are, or have been, in the military.
Father Mother Guardian Spouse
When did this individual become an active member of the military? Month ____________ Year ___________
Active Military Service (exclude reserve time) from: Month _________ Year _______ to: Month _________ Year ______
Was Kentucky the state of residency at time of induction?
If no, what date, if any, did address change to Kentucky? Month ______________ Year ______________
Do you qualify to receive Post 9/11 GI Bill Benefits?
Did the person maintain, or is the person maintaining Kentucky as the person’s legal residence while in the service?
Date of discharge: _______________________________
** L.E.S/Orders Provided: Yes _____ No _____
____________________________________________________________________________________________________________
If documentation is not applicable to you or is unavailable at this time, please explain why below.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
*
* Must have accompanying documentation
**Initial to indicate whether documentation is provided. If not applicable or not provided, initial next to “No.”
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Residency Application (University of Kentucky)

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Completed 2 February 2021

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