APPLICATION FOR VIRGINIA INSTATE TUITION
Completion of this form is required by the commonwealth of Virginia if you are claiming entitlement to Virginia in-state tuition rates pursuant to Section 23-7.4 Code of Virginia. All
questions must be answered. When not applicable, mark the N/A box. Section A must be completed by the applicant. Section B of this form must be completed by the parent/legal
guardian or spouse if the applicant is a dependent. Supporting documents and additional information may be requested. Return this form with your application for admission. If this
form is not submitted, you will be classified as a non-Virginia resident.
Section A - Applicant
(Please Note: While this information is not required for admission consideration, it is necessary for applicants who wish to be considered for financial aid and Hope Scholarship/Lifetime Learning tax credit
to provide a Social Security number to the university.) To protect your privacy, your Social Security number will not be used as your student identification number.
1. Name
_______________________________________________________________________________________ 2. Social Security Number ___ ___ ___-___ ___-___ ___ ___ ___
3. Date of Birth ___ ___-___ ___-___ ___ 4. Citizenship
U.S. Permanent resident alien, political asylum or refugee Non-U.S. If non-U.S., give visa type __________________________
5. Where have you lived in the past two years? (List current address first. Include dates.)
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________________________________________
Street address City State ZIP Code From (MM/DD/YY) To (MM/DD/YY)
6. Students under the age of 24 are presumed to be dependent on a parent or legal guardian unless
one of the following applies? (Place a check mark beside all that apply.)
Age 24 or older as of the first day of the semester in which you intend to enroll
Veteran or active duty member of the U.S. Armed Forces
Graduate or professional student
Ward of the court or was a ward of the court until age 18
Both parents are deceased, no adoptive or legal guardian
Legal dependents other than a spouse
Independent student (attach federal and state tax forms)
Married
7. Do your parents or legal guardian provide over half of your financial support or claim you as a tax
dependent? Yes No N/A
8. If you are married, do you wish to claim eligibility for in-state tuition rates based on your
spouse’s domicile? Yes No N/A
If Yes, does your spouse provide more than 50 percent of your financial support?
Yes No N/A
If “Yes” to either No. 7 or 8, Section B must be completed by a parent/legal guardian or spouse.
9. Will you have filed a tax return or paid income taxes to any state other than Virginia during the
past year? Yes No N/A
If yes, which state(s)?_________________________________
10. For at least one year prior to the semester in which you will enroll,
will you have:
a. Filed a tax return or paid income taxes to Virginia on all earned income?
Yes No N/A
b. Been a registered voter in Virginia? Yes No N/A
c. Held a valid Virginia driver’s license? Yes No N/A
11. Do you own or operate a motor vehicle? Yes No N/A
If “Yes,” has it been registered in any state other than Virginia during the past year?
Yes No N/A
12. Are you a member of the U.S. Armed Forces? Yes No N/A
If No, go to No. 13.
a. Have income taxes been paid to Virginia on all military income for the last year?
Yes No N/A
If No, have income taxes been paid to another state? Yes No N/A
b. Does the current Leave/Earnings Statement reflect Virginia withholding?
Yes No N/A
If Yes, effective date of change to Virginia: ____________________________________
(Attach a copy of your LES and DD-2058.)
13. Is your parent/legal guardian or spouse a member of the U.S. Armed Forces?
Yes No N/A
If No, go to No. 14.
a. Have income taxes been paid to Virginia on all military income for the last year?
Yes No N/A
If No, have income taxes been paid to another state? Yes No N/A
b. Does the current Leave/Earnings Statement reflect Virginia withholding?
Yes No N/A
If Yes, effective date of change to Virginia: ______________________________________
(Attach a copy of your LES and DD-2058.)
c. Has your parent/legal guardian or spouse claimed you as a dependent for federal and state
income taxes? Yes No N/A
14. Is your parent/legal guardian or spouse a retired military member, who currently resides in
Virginia and resided in Virginia at the time of their retirement?
Yes No N/A
If No, go to No. 15. If Yes, effective date of change to Virginia: ________________________
(Attach a copy of your LES and DD-2058.)
15. If your spouse is in the military, will you have:
a. Resided in Virginia for the past year? Yes No N/A
b. Paid income taxes to Virginia on all earned income? Yes No N/A
16. If your parent/legal guardian is in the military, will the nonmilitary parent/legal guardian have:
a. Resided in Virginia for the past year? Yes No N/A
b. Paid income taxes to Virginia on all earned income? Yes No N/A
c. Claimed you as a dependent for federal and state income tax purposes?
Yes No N/A
17. If you have lived outside Virginia for the past year, will you have:
a. Paid Virginia income taxes on all taxable income earned in Virginia during the past year?
Yes No N/A
b. Lived in a contiguous state to Virginia? Yes No N/A
18. If your parent/legal guardian or spouse has lived outside Virginia for the past year, will the
parent/legal guardian or spouse have:
a. Paid Virginia income taxes on all taxable income earned in Virginia during the past year?
Yes No N/A
b. Lived in a contiguous state to Virginia? Yes No N/A
c. Claimed you as a dependent for federal and state income tax purposes?
Yes No N/A
I certify that all of the information I provided in this application is true and accurate. I understand that this application is a legally binding document and that if I provide fraudulent information, I may be
subject to repayment of tuition or dismissal. I agree to furnish the university with supporting documentation related to my application, if I am requested to do so.
Signature of applicant (required)
_________________________________________________________________________________ Date _______________________________________
Last First M.I. Other (Last Name)
For office
use only.
Term
R N
Office of Admissions • 821 W. Franklin St. • Box 842526 • Richmond, VA 23284-2526 • vcu.edu/admissions
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Date _____________Initials_________
