!!
1. Name!of!Applicant!!!!!!!! !! !! !! !!! !!!!!!!__________! !! !! !!
!! !! !! (Last)!! !! !! !! !! !!(First)!! !! !! !! !!(MI)!!
2. Social!Security!Number:!!!! !________________________! !! !!
!!
3. Are!you:!!!!!!!!!☐!US!Citizen!!!!!!!!!!!!!☐Non-US!Citizen!!!☐Permanent!Resident!!!!!!!If!not!a!US!citizen,!att a ch !a n !o ff icia l!d o c u ment!
verifying!your!immigrant!status.!!
!
!
4. First!date!of!present!stay!in!South!Carolina!!! !! !/!!! !!!!!/! !!
!! !! !! !!!!!!!!!!Month!!!!!!!Day!! !!!!!!!Year!!
!
!
5. In!what!S o u th !C a ro lin a !C o u n ty !d o !yo u !re s id e ?! ! !! !! !! !! !! !!!!
! Date!present!stay!in!that!county!began!!!!! !/!!! !/!!! !!
! !!!! !! !!!!Month!! !!!!Day!! !!!!Year!!
!
!
6. Do*you*have*a*South*Carolina*Driver’s*License/Permit*or*I.D.?*
☐
Yes!!☐!No!!!Issue*Date**** _*/*** */*** *!
! !! !! !! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!Month!!!!!Day!!!!!!Year!!
7. !Are!you!currently!considered!a!resident!of!another!state!while!you!have!been!living!in!South!Carolina?!!☐Yes!!☐!No!!
! If!so,!whic h !s ta te ?!! ! !! !! !! !!
!!
8. Your*present*address*and*phone*number:*!
! *** ** ** **** **** ** *** ** *!
! !Street!! !! !!!!!!!!!!!!!City/State!! !!!Zip!! !! !!!!!!!!!Area!Code/Phone!!
!
!
9. Full-time!employment!for!the!past!year:!(If!none,!please!state!“none”)!!
! Employer%%%% %% %from%(M o.%/Yr.)% %To%(Mo.%/Yr.)%% !!
!!
10. Are!you!a!dependent!child!or!spouse?!!!!☐!Yes!!☐! No!!!!!
If!yes,!provid e !th e !fo llo wing!information!for!th e !p er so n !who!claim e d !yo u !a s !a!d e p e n d e n t!o r!e x emption!on !la s t!ye a r’s !fe d e ra l!
income!t ax !re tu rn :!!
a. Name!of!person!!! !! !! _______________!! !!!!Relationship!!________________________! !! !
If!the!perso n !h a s !leg a l!custody!of!you,!give!the!date!legal!custody!granted!_____________________!!! !! !!
b. Citizenship!! !☐!!US!Citizen!! !☐Non-US!Citizen!! !☐!!Permanent!Resident!!
If!person!is !n o t!a n !U S !cit ize n ,!a tta c h !a n !o ffic ia l!d o cu ment!verifyin g !th e !p er so n ’s !vis a !s ta tu s .!!
c. How!long!has!the!person!been!a!legal!resident!of!South!Carolina?!!__________.!
d. Does*he/she*have*a*SC*Driver’s*License?****___Yes!__!No!!!!!!Issue*Date *****Mo.____*Date*____ *Y e ar *_ __ _ *(p ro v id e *a *co p y *of *
their*SC*Driver’s*License ).!
e. Address!where!the!person!in!item!10!has!phys ically!resid ed !for!the!p ast!ye ar:!!
! ** ** ***** **** ** *** ** *!
!!!!!!!!!!!!!!Street!! !!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!!City/State! !!!Zip!! !! !!!!!!!!Area!Code/Phone!!
f. Full-time!employment!of!person!named!in!item!10!for!the!past!year:!!
! Employer%%%% %% %from%(Mo.%/Yr.)%% To%(Mo.%/Yr.) !!
!!
I%have%rea d %a n d %u n d e r sta n d %t h e %in fo rmation%pr o vid e d %f o r%R e sidency%Certif ica tio n %and%agree%to%comply%with%all%governing%rules.*I%
certify%that%all%the%information%provided%is%true%and %a c curate.%%I%und e r st a n d %t h a t%if %I%p ro v id e %e r ro n e ous%inform ation%in%an %a tt e mpt%
to%evade%payment%of%higher%student%tuition%and%fees,%I%w ill%b e%c h a rg e d%r e tro a ct ive ly %th e %d iff er e n ce %b et w e e n %w h a t%I%p a id %a n d%what%I%
should%have%paid.%%I%also%understand%that%I%may%be%subject%to%other%penalties.%!
%!
!! !! !! !!! !! !!
Signature*of*Applicant!! !! !! !! !! !! !! Date!!
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