LAST NAME __________________________________________ FIRST NAME _______________________________________ MI ________
AD
DRESS ___________________________________________________________________________________________________________
(Number, Street, and Apartment, if applicable) City State Zip Code
PHONE # _____________________ DATE OF BIRTH ______________ EMAIL _____________________________________________
When did your PRESENT stay in California BEGIN? ______________/___________/______________
Month Day Year
If you lived outside of the state of California, list the states, dates and the parent/guardian with whom you resided before your present stay
in California began:
___________________________________________________________________________________________________________________
State Dates Parent/Guardian
Citizenship Status
U.S. Citizen
Permanent Resident (must list card number and date issued)
Number: __________________________ Date Issued: ______________/___________/____________
Month Day Year
Temporary Resident
Visa (type): _______________________ Country of Issue: _____________________________________________
(If you have applied for a change of status from a Visa that cannot establish residency to a Visa that can establish residency,
you may not be classified as a resident until the Visa has been granted (proof required).
Note: Immigration documentation may be required in order to process any changes in residency regarding permanent resident status.
(Examples include Notice of Action, Employment Authorization documents, etc.)
List the STATE that you have the following:
Driver’s License or Identification Card: _____________(state) Date Issued: ______________/___________/_____________
Month Day Year
Vehicle Registration: _______________(state and date) Voter Registration #: _________________ (State)
Are you UNMARRIED and UNDER 19 years of age? Yes No
Are you declared as a DEPENDENT on your parent(s) state income tax return? Yes No
I reside with one or both of my parents and he/she/they have lived continuously at the following California address: _____________________
__________________________________________ Since: _______________________ Parent/Guardian Name: _________________________
If you have not been claimed as a DEPENDENT list the STATE and YEAR of the last 2 personal Income Tax Returns you filed
State: ________________ Year: _______________ State: ______________ Year: _______________
If NO taxes were filed, please explain: ______________________________________________________________________________________
Are you an ACTIVE duty military member? Yes No Were you discharged? Yes No
Are you a DEPENDENT of an active military person? Yes No
NOTE: If you are on ACTIVE duty orders, please attach a copy of your permanent change of station orders.
I DECLARE UNDER PENALTY OF PERJURY, THAT THE STATEMENTS SUBMITTED ON THIS RESIDENCE STATEMENT AND APPLICATION FOR
ADMISSION ARE CORRECT, and I also understand that falsification, withholding pertinent data or failure to report changes in residence, may
result in my dismissal from Napa Valley College.
Student’s Signature _______________________________ Date ___________________
Admissions and Records
2277 Napa-Vallejo Highway, Napa, Ca. 94558
707.256.
7200 fax 707.256-7219
Statement of Legal Residence
NVC Student ID#
PRINT ALL INFORMATION CLEARLY – Information that is deemed relevant and necessary to determine your residency status for tuition purposes pursuant to Education code
Section 68041. This form is to be completed and returned with documentation proving residency. Failure to answer all questions may cause your classification consideration to
be that
of a non-resident. For further information pertaining to residency, please refer to the college website at http://www.napavalley.edu
.
FALL SPRING SUMMER YEAR: _______
(Please indicate which semester/year you are applying for)
For Office Use Only
Approved Denied
Assistant Registrar, Admissions and Records
Res Code: __________Term: __________
Date Processed: ____________________
Comment
:
