PLEASE PRINT ALL INFORMATION CLEARLY. .. … Information...Are you a U.S. Citizen? DYes DNo b) Are you a Permanent Resident of the U,S,? DYes DNo c) Are you a foreign national whose

RESIDENCY INFORMATION

All students must complete this section. Texas Higher Education Coordinating Board Rule 21.731 requires each student applyil"€ to enroll at an institution to respond to a set of core residency questions for the purpose of determining the student's eligibility for classification as a resident.

PLEASE PRINT ALL INFORMATION CLEARLY.

LAST NAME FIRST NAME. .. SUFFIX ­

. :.' . .:t. PLACEOF BIRTH: STATE PLACE"OFBIRTH:COUNTRY .'

PIease proVl'de 12 monthsof res I'dencl'. . CURRENT ADDRESS CITY : ~ .. COUNTY .

" PREVIOUS ADDRESS . ' . CITY . COUNTY .'.

I LIVE IN THE.FOLLOWING SCHOOL DISTRICT: ' ,' I

o Channelview o La Porte o Sheldon o Deer Park o Clear Creek o Galena Park o Other (list)

STATE . ZIPCODE. From: MonthlYear To.: MontliiYear I

STATE I _ ZIP~CODE From: MonthlYear . ' To:= MonthlYeaI:-.

o Pasadena

1. Are you a U.S. Citizen? DYes DNo

2. Are you a U.S. Permanent Resident? DYes DNo If"Yes," of what country are you a citizen? ___________

3. Are you a foreign national here with a visa? DYes DNo If"Yes," whattype of visa do you have? Of what country are you a citizen?

4. During the 12 months prior to the term for which you are applying, did you attend a public college or university in Texas for a falI or spring term? DYes DNo If you answered "no", continue with item #5. If you answered "yes", continue with questions a - d below, then continue to item # 12.

a.) What Texas public institution did you last attend? (Give full name, not initials). b.) In which terms were you last enrolled? (Check all that apply). _ fall, 200_ _ spring, 200_ c.) During your last semester at a Texas public institution, did you pay resident (in-state) or non-resident (out·of-state)?

_ resident (in-state) _ non-resident (out-of-state) _ unknown d.) If you paid in-state tuition at your last institution, was it because you were classified as a resident or because you were a non·resident who received a

waiver? _ resident (in-state) _ non-resident (out-of-state) unknown

5. Are you a resident of Texas? DYes DNo If you answered "no"; of what state or country are you a resident? You are classified a non·resident, continue with item # 12.

If you answered "yes", answer questions a - e: a.) Did you graduate from high school or complete a GED in TX? DYes DNo b.) If you graduated from high school, what was the name and city of the school? c.) Did you live in TX the 36 months leading up to high school graduation or completion of the GED? DYes DNo d.) When you begin the semester for which you are applying, will you have lived in TX for the previous 12 months? DYes DNo e.) Are you a U.S. Citizen or a Permanent Resident? DYes DNo

If you answered "no" to any question: a, c, or d continue to item #6. If you answered "yes" to questions a, c, and d; but "no" to question e, then continue to item # 12. If you answered "yes" to questions a - e, continue to item # 12.

6. Do you file your own federal income tax as an independent tax payer? DYes DNo If you answered ''yes'', continue with item #9.

7. Are you claimed as a dependent or are you eligible to be claimed as a dependent by a parent or court-appointed legal guardian? DYes DNo If you answered "yes", to question #7, continue to item #8. If you answered."no", to both question #6 and #7, who provides the majority of your support?

Self Parent or Guardian _ Other: (List) _,--_______ If you answered "Self" to the question above, continue to item #9. If you answered "Other" to the question above, continue to item # 10 and give an explanation; then complete item #12.

8. Ifyour claim of residence status is based upon your parent or court-appointed legal guardian, answer the following questions: a.) Is the parent or legal guardian upon whom you base your claim of residency a U.S. citizen? DYes DNo b.) Is the parent or legal guardian upon whom you base your claim of residency a Permanent Resident? DYes DNo

c.) Is this parent or legal guardian a foreign national whose application for Permanent Resident Status has been preliminarily reviewed? (He or she should have received a fee/filing receipt or Notice of Action (1-797) from the USCIS showing his or her 1-485 has been reviewed and has not been rejected). DYes DNo

d.) Is this parent or legal guardian a foreign national here with a visa or a Refugee, Asylee, Parolee or here under Temporary Protective Status? DYes DNo if so, indicate which: _____--==--_-=_

e) Does this parent or legal-guardian currently live in Texas? DYes DNo If he or she is out of state due to a temporary assignment by his or her employer or other temporary purpose, please explain in item #7.

f) Ifhe or she is currently living in Texas, how long has he or she been living here? __ months __ years What is your parent's or legal guardian's main purpose for being in the state? DGo to College DEstablishlMaintain a home DWork Assignment.

g) If he or she is a member of the U.S. military, is Texas his or her Home of Record? DYes DNo What state is listed as his or her military legal residency for tax purposes on his or her Leave and Earnings Statement? State

h.) Do any of the following apply to your parent or guardian? (Check all that apply): Hold the title to real property (home, land) in Texas? DYes DNo If yes, date acquired: _______ Own a business in Texas? DYes DNo If yes, date acquired: ______ Hold a state or local license to conduct a business or practice a profession in TX? DYes DNo If yes, date acquired: ______

i.) For the past 12 months, has your parent or guardian: (Check all that apply): Been gainfully employed in TX? DYes DNo Received services from a social services agency that provides services to the homeless? DYes DNo

j) Is your parent or legal-guardian married to a person who could answer "yes" to any part of questions h - i? DYes DNo If yes, indicate which question could be answered "yes" by your parent or guardian's spouse: ______ How long has your parent or guardian been married to the Texas resident? __months ~ears

9. If your claim of residence status is based upon self, answer the following questions: a.) Are you a U.S. Citizen? DYes DNo b) Are you a Permanent Resident of the U,S,? DYes DNo c) Are you a foreign national whose application for Permanent Resident Status has been preliminarily reviewed? (You should have

received a fee/filing receipt or Notice of Action (1-797) from the USCIS showing your 1-485 has been reviewed and has not been rejected). DYes DNo

d) Are you a foreign national here with a visa or a Refugee, Asylee, Parolee or here under Temporary Protective Status? DYes DNo If so, indicate which: .

e) Do you currently live in Texas? DYes DNo If you are out of state due to a temporary assignment by your employer or other temporary purpose, please explain in item #7.

f) If you are currently living in Texas, how long have you been living here? __ months ~ears What is your main purpose for being in 'the state? DGo to College DEstablishlMaintain a home DWork Assignment If for reasons other than those listed, give an explanation in item #7.

g) If you are a member of the U.S. military, is Texas your Home of Record? DYes DNo What state is listed as your military legal residence for tax purposes on your Leave and Earnings Statement? Stale

h.) Do any of the following apply to you? (Check all that apply): Hold the title to real property (home, land) in Texas? DYes DNo If yes, date acquired: ______ Own a business in Texas? DYes DNo If yes, date acquired: ______ Hold a state or local license to conduct a business or practice a profession in TX? DYes DNo If yes, dateacquired: ______

i,) For the past 12 months, have you: (Check all that apply): Been gainfuJly employed in TX? DYes DNo Received services from a social services agency that provides services to homeless persons? DYes DNo

j) Are you married to a person who could answer "yes" to any part of questions h - i? DYes DNo If yes, indicate which question could be answered "yes" by your spouse: ______ How long have you been married to the Texas resident? __ months ~ears

10. General Comments. Is there any additional information that you believe your college should know in evaluating your eligibility to be classified as a resident? Ifso, please provide it below:

II. Of what state or country are you a resident? ___________

12. Certification of Residency. All students must complete this section. I understand that officials of my college/university will use the information submitted on this form to determine my status for residency eligibility. I authorize the college/university to verify the information I have provided. I agree to notify the proper officials of the institution of any changes in the information provided. I certify that the information on this application is complete and correct and I understand that the submissions of false information is grounds for rejection of my application, withdrawal of any offer of acceptance, cancellation of enrollment and/or appropriate disciplinary action.

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