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Page 1 of 6
Admissions&RecordsOffice
11711SandCanyonRoad
Yucaipa,CA.92399‐1799
P:(909)389‐3372
Web:www.CraftonHills.edu
CraftonHillsCollege
SupplementalResidency
Questionnaire
Students may be required to complete a supplemental residency questionnaire to clarify residency or apply for a residency
reclassification. Residency changes are not automatic. Residency will not be changed once the semester has begun.
To be considered for California residency, you must:
1. Be physically present in California for at least one year and one day prior to the start of the semester.
2. Show documentation of intent to establish California residency dating at least one year and one day prior to the start of the
semester.
3. Not be precluded from establishing residency by provisions of the Immigration and Nationality Act.
PART A – TO BE COMPLETED BY ALL STUDENTS
Semester Reclassification requested for (check only one): Spring Summer Fall Year: 20______
Print Full
Legal Name: ____________________________________________________________ Student ID # ______________________
Last First Middle
7-Digit SBCCD ID #
Birth Date: ______/______/______ Age: ________ Birthplace: _________________________________________________
Physical
Address: ____________________________________________________________ Home Phone: (______) ______-________
City: ___________________________ State: ______ Zip Code: ____________ Work Phone: (______) ______-________
E-Mail Address: _______________________________________________________ Cell Phone: (______) ______-________
Are you a United States citizen? Yes No Other Phone: (______) ______-________
When did your present stay in California begin? _____/_____/_____
Have you lived at your current physical address continuously for the last two years?
Yes No
If you answered “NO,” list your previous addresses for the past two years (in descending order):
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
In The Last Year, Have You:
Registered to vote or voted in a state other than California? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Petitioned for a divorce as a resident of another state? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Attended an out-of-state institution as a resident of that state? . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Declared non-residence for California income tax purposes? . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
If you answered “Yes” to any of the questions above, please give a brief explanation:
Valley College
San Bernardino
Admissions & Records Oce
701 S. Mt. Vernon Ave.
San Bernardino, CA 92410
Phone: (909) 384-4401
Web: www.valleycollege.edu
San Bernardino Valley College
Supplemental Residency
Questionnaire
Wyoming
Wyoming
Wyoming
Wyoming
Wyoming
Page 2 of 6
PART B – TO BE COMPLETED BY ALL STUDENTS UNDER 19 YEARS OF AGE
1.
(a) Mother’s Name: _________________________________________________________________
(b) Is your mother living? Yes No If “No,” Date Deceased: _____/_____/_____
If answer to (b) was “Yes,” answer the following:
(c) Is your mother a
United States citizen?
Yes No
If “No,” what is her immigration status?
_________________________________________________________
(d) M other’s Permanent Address:
___________________________________________________________________________
(e) If in California, for
how long? __________
( f)
Has your mother lived at her current address continuously for the last two years?
Yes No
(g) If the answer to (f) was “No,” list your mother’s previous addresses for the past two years (in descending order):
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
(h )
In The Last Year, Has Your Mother:
Registered to vote or voted in a state other than California? . . . . . . . . . . . . . . . . . . . . . . . Yes No
Petitioned for a divorce as a resident of another state? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Attended an out-of-state institution as a resident of that state? . . . . . . . . . . . . . . . . . . . . . Yes No
Declared non-residence for California income tax purposes? . . . . . . . . . . . . . . . . . . . . . . Yes No
2.
(a) Fath er’s Name: _________________________________________________________________
(b) Is your father living? Yes No If “No,” Date Deceased: _____/_____/_____
If answer to (b) was “Yes,” answer the following:
(c) Is your father a
United States citizen?
Yes No
If “No,” what is his immigration status?
_________________________________________________________
(d) Father’s Permanent Address:
___________________________________________________________________________
(e) If in California, for
how long? __________
( f)
Has your father lived at his current address continuously for the last two years?
Yes No
(g) If the answer to (f) was “No,” list your father’s previous addresses for the past two years (in descending order):
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
______________________________________________________________________ _____/_____ - _____/_____
No. Street City State Zip Code Start Mo/Yr End Mo/Yr
(h )
In The Last Year, Has Your Father:
Registered to vote or voted in a state other than California? . . . . . . . . . . . . . . . . . . . . . . . Yes No
Petitioned for a divorce as a resident of another state? . . . . . . . . . . . . . . . . . . . . . . . . . . . Yes No
Attended an out-of-state institution as a resident of that state? . . . . . . . . . . . . . . . . . . . . . Yes No
Declared non-residence for California income tax purposes? . . . . . . . . . . . . . . . . . . . . . . Yes No
3.
(a) Where do you live? With Mother With Father Somewhere Else
(b) If you do not live with either parent, are you under continuous and direct care and
control of any person or persons other than a parent?
Yes No
If “Yes,” give the name and address of such person:
Name: _______________________________________________________________________
__________________________________________________________________________________________
No. Street City State Zip Code
How long have you been continuously under this person’s direct care and control? _________________________________
You must bring at least three (3) items documenting your parent’s or guardian’s California residency. The documentation
items must be valid, legible, and cover the one year and one day period before the first day of the semester
. See part E for a
list of acceptable documents.
Wyoming
Wyoming
Wyoming
Wyoming
Wyoming
Page 3 of 6
PART C – TO BE COMPLETED BY ALL STUDENTS WHO ARE NOT UNITED STATES CITIZENS
Information collected on this questionnaire will not be reported to any United States government agency, including but not
limited to, the U.S. Bureau of Citizenship, Immigration Services or Department of Homeland Security unless specifically
requested by such an agency.
1. What is your immigration status? (Check One)
�
Nonimmigrant Visa Holder
Type: __________
Date Issued: _____/_____/_____ Expiration Date: _____/_____/_____ � Check here if no expiration date.
Entry Date: _____/_____/_____ Admitted Until: _____/_____/_____
�
Lawful Permanent Resident Alien (Green Card Holder)
Adjustment Date: _____/_____/_____
Alien Number: A#______________________________
�
Applicant for Lawful Permanent Residence
Date Applied: _____/_____/_____
If you have an immigrant visa, enter type: __________
�
Lawful Temporary Resident (or Applicant for Lawful Temporary Residence)
Adjustment Date: _____/_____/_____
Alien Number: A#______________________________
If an applicant, date applied: _____/_____/_____
�
Political Asylee or Asylum Applicant
Date Applied/Granted: _____/_____/_____
�
Refugee
Date Applied/Granted: _____/_____/_____
�
Family Unity Program Beneficiary (or Applicant)
Date Applied/Granted: _____/_____/_____
�
Temporary Protected Status (“TPS”) (or Applicant for TPS)
Date Applied/Granted: _____/_____/_____
�
Violence Against Women Act (“VAWA”) Self-Petition Grantee (or Applicant for Self-Petition)
Date Applied/Granted: _____/_____/_____
�
Other
Check here if your status is not listed above, you entered the United States without the authorization of
the U.S. Bureau of Citizenship or Immigration Services or if your visa expired.
2. If you have a Work Authorization Card (e.g., I-688B), enter the following:
Category (i.e., Provision of Law): ______________________________
Card Valid From: _____/_____/_____
Expires: _ ____/_____/_____
You must bring documentation of your immigration status with you. If you are under 19, you must also bring documentation
of your parent’s or guardian’s immigration status as well.
Page 4 of 6
PART D – SPECIAL EXCEPTIONS TO BE COMPLETED WHERE APPLICABLE
In some cases, even if you have not been in California for more than a year and one day, you may still qualify for either residence classification or a
tuition/fee waiver under one of the following special exceptions provided by law. Check if any one of the following exceptions applies, and please
bring the requested documentation (an original and one copy) with you.
Self Support (T5 §54040)
If you are under 19 years of age, and you have supported yourself
financially for at least one year and a day, please provide the following:
(1) Documentation of employment (either W-2 forms or a letter
from your employer showing earnings for the past year),
(2) A statement that you have actually been present in California
for the past year, AND
(3) A statement showing all your expenses for the past year.
Dependent of a Military Member (T5 §54041)
If you are a child or spouse of a member of the armed forces of the
United States who is stationed in California, please provide the
following:
(1) A statement from the military person’s commanding officer or
personnel officer, AND
(2) Evidence that you are a dependent of the military person’s for
federal tax purposes.
Military Member on Active Duty in California (T5 §54042)
If you are a member of the armed forces of the United States stationed in
California on active duty and not assigned for educational purposes to an
SBCCD college, please provide the following:
(1) A statement from your commanding officer or personnel
officer that the assignment to active duty in California is not
for educational purposes AND
(2) Evidence of the date of assignment to California.
Military Member Remaining in California After
Discharge
(EC §68075.5)
If you were: (1) a member of the armed forces of the United States who
was stationed in this state on active duty for more than one year
immediately prior to being discharged AND (2) have remained in
California after your discharge for less than a year and one day, you may
be eligible for resident classification. Please provide a copy of your
Military Discharge Form, DD-214.
AB540 Exempt (T5 §54045.5, EC §68130.5)
If you attended a California high school for at least three (3) years and
graduated or received a certificate of completion, please submit the
following:
(1) AB540 Tuition Exemption form.
(2) Official sealed high school transcripts.
Public School Employee With a Valid Credential or
Emergency Permit
(T5 §54046)
If you hold a valid credential or a valid emergency permit authorizing
service in the California public schools, are employed by a school district
in a full-time position, and are enrolling in an SBCCD college to fulfill
credential requirements, please provide the following:
(1) A statement from your employer showing that you are
employed in a full-time position requiring certification
qualifications AND
(2) A copy of your credential.
Adult Dependent of a California Resident (EC §68076)
If you have not been an adult resident of California for more than one
year and you either (a) are the dependent child of a California resident
who has residence in California for more than one year or (b) have a
parent who has both contributed court-ordered support for you on a
continuous basis and has been a California resident for a minimum of
one year, please provide documentation of your parent’s California
Residency.
Agricultural Laborer for Hire (or Child of Such Laborer)
(T5 §54048)
(“Agricultural labor for hire” means seasonal employment in connection
with actual production of agricultural crops, including seeding, thinning
and harvesting.) If your parent
earns a livelihood by performing
agricultural labor for hire, please provide the following: (1) Evidence
that your parent with whom you live earns a livelihood primarily by
performing agricultural labor for hire and has performed such labor in
California for at least two months in each of the two preceding years, (2)
Evidence that your parent lived within the district, AND (3) Proof that
your parent claims you as a dependent on his/her income tax return, if
your parent had sufficient income to incur personal income tax liability.
If you
are an agricultural laborer for hire, please provide evidence
showing that you earn a livelihood primarily by performing agricultural
labor for hire and that such labor has been performed in California for at
least two months in each of the preceding two years.
Graduate of a School in California Operated by the
United States Bureau of Indian Affairs
(EC §68077)
If you are a graduate of any school located in California that is operated
by the United States Bureau of Indian Affairs, including, but not limited
to, the Sherman Indian High School, please provide a copy of your
diploma.
Full-Time Employee of a California State Agency
Assigned to Work Outside California (or Child or Spouse
of Such Employee)
(EC §68079)
If you, your parent or spouse is a full-time employee of a California state
agency (i.e., any office, department, division, bureau, board or
commission of the state of California) and assigned to work outside
California, please provide the following:
(1) Evidence of such employment AND
(2) Evidence of the out-of-state assignment.
Relocated Federal Civil Service Employee (or Child of
Such Employee)
(EC §68084)
If you or your parent is a federal civil service employee who moved to
California as a result of military mission realignment action that involved
the relocation of at least 100 employees, please provide:
(1) Evidence of such employment AND
(2) Evidence of the reassignment to California.
To Be Hired By a Public Agency as a Peace Officer
(EC §76140.5)
If a public agency (e.g., city, county, district or other local authority or
public body of or within the state of California) intends to classify you as
a peace officer upon successful completion of a police academy training
course at an SBCCD college, please provide the following:
(1) Evidence that you have passed all other requirements of the
hiring public agency AND
(2) Evidence that the public agency intends to classify you as a
peace officer.
Surviving Dependent of Any Individual Killed in the
September 11
th
Attacks (EC §76300 (j))
If you are a surviving dependent of an individual killed in the September
11, 2001 terrorist attacks (i.e., the World Trade Center in New York
City, the Pentagon in Washington, D.C., or the crash of United Airlines
Flight 93 in Pennsylvania) and you were given written notice of
eligibility for a tuition and fee waiver by the California Victim
Compensation and Government Claims Board, please provide a copy of
your notice of waiver.
Page 5 of 6
PART E – TO BE COMPLETED BY ALL STUDENTS
Residence Determination Date
“Residence determination date” is that day immediately preceding the opening day of instruction of the quarter, semester, or other
session as set by the district governing board, during which the student proposes to attend a college. (T5 §54002)
One-Year Waiting Period
The one-year residence period which a student must meet to be classified as a resident does not begin to run until the student both is
present in California and has manifested clear intent to become a California resident. (T5 §54028)
Required Documentation for Residency
The burden of proof is on the student to clearly demonstrate both
physical presence in California and intent to establish a permanent
home in California. You are required to present evidence in accordance with Education Code Sections 68040 et seq.
You must bring three (3) of the following kinds of documentation from the list below. The documents presented must be valid, legible
and cover the one year and one day period before the first day of the semester. Documents must be properly identified with the
student’s name and a corresponding California address.
*** MUST SUBMIT THREE (3) OR MORE ITEMS FROM THE FOLLOWING LIST ***
No item/category may be used more than once.
3
Activity/Documentation Date Issued/Begun
Documentation of ownership and continuous occupancy of residential property or continuous occupancy of rented
or leased property, in California, covering the one-year period prior to the Residence Determination Date.
_____/_____/_____
Documentation of Voter Registration and voting in California.
_____/_____/_____
Licensing from California for professional practice.
_____/_____/_____
Active membership in service or social club in California.
_____/_____/_____
Showing California as home address on federal income tax return (Form 1040) from previous year.
_____/_____/_____
California State income tax return filed as a resident (Form 540) from previous year coupled with employment pay
stubs dated prior to the determination date of residency. Pay stubs must reflect the student’s employment.
_____/_____/_____
Valid California Motor Vehicle Registration.
_____/_____/_____
Possessing a California driver’s license or identification card.
_____/_____/_____
DL/ID #
____________________ Expiration Date: _____/_____/_____
Military records in student’s name showing California as the home of record (i.e. Copy of Orders, Military I.D., and
DD214)
_____/_____/_____
Statements from an active bank account in California; must provide statements dated prior to the determination date
of residency and current statements to verify the account is still active.
_____/_____/_____
Petition for a divorce in California.
_____/_____/_____
Receipts showing payment of non-resident tuition at an out-of-state institution (outside California) with a California
permanent home address.
_____/_____/_____
Utility bills (gas, water, power, telephone) covering the one-year period prior to the Residence Determination Date.
_____/_____/_____
Documentation of public assistance, rehabilitation, unemployment, or other California state services/benefits
received from a California state agency covering the one-year period prior to the Residence Determination date.
_____/_____/_____
Proof of jury duty service in a California court within the past year.
_____/_____/_____
Selective Service registration with a permanent California address.
_____/_____/_____
Please list below other things you have done to justify your request to be classified as a California resident. Physical presence within California
solely for educational purposes does not establish residency.
Page 6 of 6
DECLARATION – TO BE COMPLETED BY ALL STUDENTS
¾
Do not fax this form. You must submit the following as a packet to the Admissions & Records Office (SSA-
213) in-person or by mail:
o Valid Photo Identification (copy if mailing packet),
o Supplemental Residency Questionnaire,
o A copy of all documentation provided to be attached to this form.
If you have questions about completing this form, required documentation, exceptions or the residency classification procedure, please
contact the Admissions & Records Office at (909) 38
4-4401.
WARNING: Falsifying information about citizenship, California residency, financial aid, and/or military status could result in:
(1) criminal charges for perjury and/or fraud and, if convicted, imprisonment;
(2) student disciplinary action; and/or
(3) accumulated monetary charges such as for restitution or nonpayment of nonresident fees.
I certify under penalty of perjury that all the information I have given on this form, including any attachments, is true and complete to
the best of my knowledge. I understand that falsification or withholding of information requested shall constitute grounds for
dismissal. I understand if it is determined I do not meet the requirements to be classified as a resident, I will be responsible for
payment of nonresident fees. I understand that failure to pay these fees in accordance with the College’s payment policy will result in
my courses being dropped for non-payment. I understand that I will be requested to provide proof of some statements in accordance
with Education Code Sections 68040 et seq.
__________________________________________________
______/______/______
Student’s Signature Date
FOR OFFICE USE ONLY
Residence Determination Date:
______/______/______
Residence Determination:
CCCApply Reviewed
California Resident
Resident as of: ______/______/______
Datatel Residency Status Updated
Non-Resident
Resident of:
State: __________
Foreign Country
Semester Charges Recalculated in
Datatel
Non-Resident Qualifying for a Special Exception
Pending: Documentation does not cover one (1) year period.
Documentation does not show intent.
Other (see notes below).
Notes/Comments:
__________________________________________________
______/______/______
A&R Staff Signature Date
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Completed 26 May 2020

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