Updated: 11.9.2018
Signature of ACC Staff: _______________________________ Extension:_________ Date: ____________
Verified Proof of Residency
Student Information:
Student Name:
Student ID:
Student Email:
Proof of Residency Information:
The following information is provided as proof of residency of a student as required under C.R.S 22-1-102
I verify that I am the owner/lessor of the following property:
Home Owner Name:
Home Owner Address:
Dates Student Resided/Will be Residing at
Above Address:
Proof of Residency Documentation
Check the proof of ownership or occupancy documentation provide. Student must attached copy of documentation.
Warranty Deed
County Tax or Assessment Notice
Lease A
Purchase Agreement
Home Owner Certification:
I hereby certify that to the best of my knowledge the information furnished in this form is true and complete without the
intent of evasion or misrepresentation. I understand that if the above information submitted is found to be false or
misrepresented, the above student could be subject to penalty of perjury and is sufficient cause for dismissal.
**Home owner must sign this form in the presence of a Notary.
Home Owner S
ignature**: _____________________________________________ Date:
Notary Certification:
County & State of _____________________________________
Sworn and subscribed to me this _____ day of ______________
My Commission expires ___________________
Notary Signature ______________________________________
Notary Stamp
Records & Enrollment Services
Main Building, Room M2480
5900 S. Santa Fe Drive
Littleton, CO 80160
Fax: 303.797.5970