Fill - Free fillable Section 1 (Cascadia Community College) PDF form

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

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

3. Class Standing: Undergraduate Graduate Professional School: _______________________________________

____________________________________

Residence Classification Officer

4. 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 __________

5. 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

5c. Do you hold a visa classification of A, E, G, H-1, I, K, or L?  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.

If yes to any of the above, you must attach a copy of both sides of 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.)

6. 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.

7. 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 a true and correct copy of 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 _________________________________________________________________________________________________ Date ___________________________

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

 A true and correct copy of 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.

 A true and correct copy of 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 a true and correct copy of the first and 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

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.

Cascadia College is an equal opportunity institution and does not discriminate on the basis of race, color, religion, gender and/or sex, disability, national origin, citizenship

status, age, sexual orientation, veteran’s status, or genetic information. All Cascadia materials are available in alternative formats and can be requested by contacting the Human

Resources office.

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:

Legal Guardian  Student Parent 

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. copies of 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, attach a

copy of 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?

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

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

 Yes  No

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

6. Do you have a valid

driver's license?

If yes, you must attach

a copy of your current

driver's license.

If yes, in what state:

_________________________

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

Date ______________________________

 Yes  No

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, please attach

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, attach a copy of 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.

Signature of Parent___________________________________________ DATE ____________________

(if completing section 3)

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.

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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