Fillable Residency Declaration-PF-ADA Residency Declaration Form

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Residency Declaration-PF-ADA Residency Declaration Form

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The Residency Declaration-PF-ADA Residency Declaration Form form is 1 page long and contains:

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Country of origin: US
File type: PDF

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_____________________________________________________________________________________________________________________________
__________________________________________________________ _____________________________________________________
_____________________________________________________________________________ _______________________________________________________________________
RESIDENCY DECLARATION
APPLICANT NAME: ___________________________________________________________________ SSN: ___________________________
Print Legal Last Name First Name Full Middle Name
SECTION A - I claim legal residency in the State (or country) of: ____________________________________________ Since: ____________________
YES NO Check the appropriate box
c c I have been present in Hawai‘i continuously for the last 13 months
c c I have led a Hawai‘i Individual Tax Return as a Resident for the last two years
c c I registered to vote in the state of Hawai‘i. If no, what state: __________________
c c I voted in the last election in the state of Hawai‘i
c c My parent(s) / legal guardian(s) claimed me on their Personal Income Tax. State: ___________________
If you are less than 18 and unmarried, please answer the following questions based on your parent or legal guardian:
My parent/legal guardian:
c c Claims legal residency in the state of Hawai‘i
c c Has been present in Hawai‘i continuously for the last 13 months
c c Has led a Hawai‘i Individual Tax Return as a resident for the last two years
c c Is registered to vote in the state of Hawai‘i
c c Voted in the last election in the state of Hawai‘i
c c Is a US citizen
c c If not a US citizen, has been a permanent resident for more than one year (attach copy of green card)
Relationship to applicant: ____________________________________________________________________
Parent/Legal Guardian Signature: ______________________________________________________________ Date: __________________
If your legal guardian is court appointed, submit a copy of the court order with this application.
Section B - College Enrollment
This past year, I enrolled in a publicly supported college or university outside the state of Hawai‘i. c YES c NO (if no, skip to section C)
I paid the following tuition at that institution: c Resident c Nonresident c Resident due to nonresident exemption based on: ____________________
Section C - Exemptions from the Nonresident Tuition, leave blank if it does not apply.
c I am a full-time faculty or staff member of the University of Hawai‘i, or a spouse or legal dependent of such person (attach employment contract)
c I am Hawaiian and a resident of another state (attach an ofcial copy of your birth certicate, and if necessary, that of your parents/grandparents
documenting Hawaiian ancestry)
c I am a citizen of ___________________________ which has no public institution of higher education ranking baccalaureate degrees
c I am a member or authorized dependent of a member of the US armed forces, on active duty, stationed in Hawai‘i (complete verication below)
c I am a member of the Hawai‘i National Guard or Hawai‘i-based Reserves (complete verication below)
VERIFICATION OF U.S. ARMED FORCES - attach Military Orders
Permission is hereby granted to release information to UH Campus: Member’s Relationship to Applicant:
Applicant’s Signature: ______________________________________________ c Self c Spouse
Military Member’s Signature: ________________________________________ c Parent c Other (specify)
To be completed by the Member’s Commanding Ofcer:
Name, Rank, & Branch of Service of member of the U.S. Armed Forces on active duty stationed in Hawai‘i, or member of the Hawai‘i National Guard of Hawai‘i-based Reserves
Estimated Date (mm/dd/yyyy): ___________________________________________________________________________________________________
Rotation from Hawai‘i or separation from military service, whichever is earlier (do not use “Indenite” or leave blank)
Signature of Commanding Ofcer Date Rank and Branch of Service in Hawai‘i
Print Name Phone Number of Branch of Service in Hawai‘i
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Residency Declaration-PF-ADA Residency Declaration Form

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Completed 2 March 2020

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