Part Time Driver

COLLEGE OF THE CANYONS – ADMISSIONS & RECORDS OFFICE

R ESIDENCY R ECLASSIFICATION A FFIDAVIT

Please submit the questionnaire with all pertinent residency documentation. Incomplete questionnaires and/or questionnaires without documentation will be returned to the student:

(1) NAME (please print):

LAST FIRST MIDDLE

ADDRESS:

No. STREET CITY STATE ZIP

STUDENT ID#: SOCIAL SECURITY#:

DATE OF BIRTH: PHONE: EMAIL:

This information is deemed relevant and necessary to properly determine residency for tuition purposes pursuant to Education Code Section 68041. Failure to answer all questions may cause you to be classified as a non-resident. You are required to furnish documentation in support of your responses. RELEASE OF INFORMATION: If you would like us to be able to discuss your residency information with a third party (parent, lawyer, etc.) please provide written documentation stating who we may discuss this information and how we may discuss it with them (in person, phone, email, etc.) attached to this document.

LEGAL STATUS:

(To establish residency you need to be a US citizen, a permanent resident, an applicant for a permanent resident status, or possess a visa that does not preclude establishing domicile in the U.S.)

(2) Please mark your information below:

U.S. Citizen

Permanent Resident Number: Issue Date: Exp Date:

Refugee/Asylee Date Issued:

Current Visa Status: Issue Date: Exp Date:

Deferred Action for Childhood Arrivals (DACA)

(3) Do you hold any of the following visas? (check below)

B H-3 P

C J Q

F M TN/TD

H-2 O-2

(4) Or have you held any of the above visas in the last two years? Yes No

(Note: Verification is required. You must present proof of status.) AR35 1/21/15 PAGE 3

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27531 Santa Clarita rd Santa Clarita CA 91350

05221301

05-21-04 661-***-**** ******.******@******.***

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PHYSICAL PRESENCE AND INTENT:

(Physical presence is proved by being physically and continuously present in California for one year plus one day prior to the start of the term. Intent is proven by providing evidence demonstrating intent to make California a permanent home of residence.)

(5) You have resided in the State of California since:

(6) Do you own property in California? Yes No Date purchased:

(7) Do you rent property in California? Yes No

(If lease is less than 12 months old you will need to furnish previous lease as well.)

(8) Where were your last two years state income tax returns filed? and State/Year State/Year

(8a) If no taxes were filed explain

(9) Are you currently registered to vote in CA? Yes If No, then: State: Date:

(10) Do you possess a valid CA driver’s license or ID? Yes If No, then: State: Date:

(11) Do you have a current CA vehicle registration? Yes If No, then: State: Date:

(12) Selective Service Registration

with CA permanent address? Yes No

(13) Do you have an active CA bank account? Yes If No, then: State: Date Opened:

(14) CA License for professional practice? No If Yes, then: License No: Date:

(15) Were you employed in California this past year? Yes No Employer:

From: to

(16) List additional proof of residency and attach documentation: MILITARY STATUS:

(17) Please mark your information below:

Currently active or dependent of current active military

Member discharged within the last two years

Member discharged over two years ago (veteran)

Date of discharge:

Home state of record:

Address after separation:

Currently stationed in CA? Yes No

If stationed in CA, is the duty for educational purposes ONLY? Yes No AR35 1/21/15 PAGE 4

05-21-2004

n/a

CA

AB540 – Nonresident Tuition Exemption:

(18) Did you attend a California high school for 3 years and graduate from a California high school or obtain the equivalent thereof, such as a GED, Certificate of Proficiency, or Certificate of Completion? Yes No School: Graduation Date:

Note: You may eligible for the California Nonresident Tuition Exemption Request under AB540. Please contact the Residency Specialist for more information. FINANCIAL INDEPENDENCE:

If you are an adult student and your parents are not California residents, you must demonstrate financial independence, along with physical presence and intent. If your parents are not residents of California, you will be required to be financially independent in order to be a resident for tuition purposes. Dependent children of California residents who do not meet the physical presence are entitled to resident classification during the first year they are physically present in California; however, student must establish California residency thereafter. Please see Education Code Section 68044 and Title 5 section 54020.

(19) Were you claimed as an exemption for state and/or federal tax purposes by your parent(s) in either or both of the past two calendar years? Yes No

(20) Did you receive or will you receive more than 50% of your income as financial assistance from your parent(s) in either or both of the past two calendar years?

Yes No

(21) California W-2 forms with California address? Yes No

(22) Source of financial support for the past year?

(23) Did you live more than six weeks with your parent(s) during either or both of the past two years? Yes No

(24) Do your parents live or work in CA? Yes No

(25) If your parents are divorced/separated, indicate the state where each parent lives:

Mother Father

PLEASE NOTE: YOUR RESIDENCY RECLASSIFICATION AFFIDAVIT MUST BE SIGNED I, the undersigned, declare under penalty of perjury under the laws of the State of California the information and the documentation I have provided on this form is true and accurate. FURTHER, I UNDERSTAND FALSIFICATION OR FAILURE TO REPORT CHANGE IN RESIDENCE MAY RESULT IN MY DISMISSAL FROM THE COLLEGE. I further understand that all materials submitted by me for the purpose of residency reevaluation become the property of College of the Canyons. I understand that falsification, withholding pertinent data, or if I fail to report changes in residency I may be liable for payment of all nonresident charges from which I was exempted and may be subject to disciplinary action including dismissal from College of the Canyons.

(26) Student Signature: Date:

AR35 06/05/14 PAGE 5

Worked part time, and from help of parents

chicago California

01/17/23

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