Service Member Name: _________________________________________________________________________________________________________________
Service Member State of Entry: ___________________________________________________________________________________________________________
Service Member Permanent Duty Station: __________________________________________________________________________________________________
Service Member State of Domicile: ________________________________________________________________________________________________________
Service Member Home of Record on DD214: ________________________________________________________________________________________________
Is the service member still an active member of the armed forces? Yes | No
Service Member Station Location and Dates: ________________________________________________________________________________________________
If applicable, date service member separated from active duty: __________ / _____ / __________
I will be using Post 9/11 Transfer of Entitlement benefits: Yes | No
I will be using benefits under the Fry Scholarship: Yes | No
Date:
Student’s Signature
Full Name: ___________________________________________________________________________________________________
Student ID #: _____________________________________________________________ Date: ______________________________
VACA WAIVER OF NON-RESIDENT STATUS
PLEASE PRINT
Last Name First Name Middle Name
TR 2/12/2019
Office of Admissions & Records
3000 Campus Hill Drive, Bldg. 1600
Livermore, California 94551
Tel : (925) 424.1500
Fax : (925) 606.6437
www.laspositascollege.edu/admissions
If you are a dependent child of an active duty service member stationed or domiciled in California on active duty, submit the following documentation:
1) Statement from the service member's commanding or personnel officer listing the dates and location of assignment.
2) Service member's state or federal income tax filings with you, the dependent, listed as an exemption.
If you are the spouse of an active service member stationed or domiciled in California on active duty, submit the following documentation:
1) Statement from the service member's commanding or personnel officer listing the dates and location of assignment.
2) Your joint state or federal income tax filings.
If you are a "covered individual" under VACA Section 702, submit the following documentation:
1) Service member's form DD214.
2) Certificate of Eligibility showing you are eligible for Post 9/11 Transfer of Entitlement benefits or the Fry Scholarship.
By signing this form, you understand that any misrepresentation of information provided may result in disciplinary action in accordance with Student Disciplinary Action
and/or a financial obligation that must be paid in accordance with the processing and collection of tuition and fee payments. Further, you understand that state residency
changes will not be made retroactively and that the deadline to make a residence change is prior to the start of the enrolled term.
OFFICE USE ONLY
Approved | Denied Non-resident Waiver | California Reclassification | Out-of-State Resident
Effective Term: _______________ Effective Date: _______________ Done by: __________ Coded: __________ Student Notified: _____________________________________
QUESTIONNAIRE
You will be notified via your college Zonemail account approximately 1-2 weeks following the receipt of your request.
If you are an out-of-state veteran student under Ch. 31 Vocational Rehabilitation and Employment (VR&E), please submit the following documentation:
Effective Summer 2019: Out-of-state veteran students under Ch. 31 VR&E will be charged the resident rate.
1) Service member's form DD214
2) VA Form 28-1905, Authorization and Certification of Entrance or Reentrance into Rehabilitation and Certification of Status.
REQUIRED DOCUME
NTATION
If you have been living in California for less than one year, please follow the instructions below. If you have been living in California for
more than one year, please complete the Residency Reclassification Petition instead.
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