The Residency Manual
APPENDIX B. North Carolina Public Higher Education Residence -and-Tuition Status Application
Under North Carolina law, a person may qualify as a resident for tuition purposes in North Carolina, thereby being eligible for a tuition rate lower than that for nonresidents for tuition purposes. Copies of the applicable law and of implementing regulations are available for inspection in the ____________ and may be examined upon request.
In essence, the controlling North Carolina statute (G.S. 116-143.1) requires that "To qualify as a resident for tuition purposes, a person must have established legal residence (domicile) in North Carolina and maintained that legal residence for at least 12 months immediately prior to his or her classification as a resident for tuition purposes."
G.S. 116-143.1 also sets forth statutory definitions, rules, and special provisions for determining residence status for tuition purposes. These provisions include special rules with respect to persons who are married or who are within identified subclasses of minors. Certain aliens may also qualify for resident tuition status. The residence Manual, located at the office identified in this paragraph, should be consulted for the statutory and related regulatory conditions.
DIRECTIONS
1. Respond to all questions within the part(s) of the form that you are to complete. If any question is not applicable to your situation, write "Not Applicable" of "N/A."
2 Print or type all responses. If necessary, write "see attached" in the space provided, and use separate additional sheets, numbering your responses the same as the corresponding question and stapling or taping these sheets to this application form.
3. Be completely accurate to the best of your knowledge and understanding. Knowing falsification of your responses may subject you to disciplinary action including dismissal from the institution. When "date" is requested, give day, month, and year.
4. Sign and date this application where indicated to make those acknowledgments and certifications necessary to render this a viable application.
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1. Applicant student's full name (Miss, Mr., Mrs., Ms.)
2. Social Security Number (voluntary) ______ Citizenship
3. Date of birth Place of birth _____
4. Do you claim to be a legal resident of the State of North Carolina? (Yes) (No) If so, from what date? __________________
Note: If your response to question 4 is "no," you need not complete the rest of this form unless subsequently instructed to do so; sign and date the portion completed, at the place indicated.
5. Beginning with what term of enrollment do you claim entitlement to the in-state tuition rate, if that is your claim?
6. Address while attending this institution (current, not past) Telephone
7. Permanent home address since (date) Telephone
8. Last previous home address in N.C. was from (date) ______ (to). Last previous home address outside N.C. was from (date) (to)
9. Are you currently enrolled in this institution? (Yes) (No) Are you applying for admission? (Yes) (No)
10. Secondary (high or preparatory) school you attended, in sequence. Name Address Dates attended (place and state) (from) (to)
11. Post-secondary schools (universities, colleges, junior colleges, community colleges, etc.) you have attended, in sequence (including this institution). Name Address Dates attended (place and state) (from) (to)
If married, post-secondary schools (universities, colleges, junior colleges, community colleges, etc.) your spouse has attended, in sequence (including this institution).
Name Address Dates attended (place and state) (from) (to)
12. Has your residence status for tuition purposes ever been previously determined by any North Carolina public educational institution? (Yes) (No) If yes, (a) give name of institution
(b) circle classification: Resident Nonresident
(c) give last term and year you were so classified:
13. Father living? (Yes) (No) Name ______ Permanent home address ______ since (date) Occupation ______
14. Mother living? (Yes) (No) Name ______ Permanent home address ______ since (date) Occupation ______
15. Are parents separated or divorced? (Yes) (No) If yes, who has custody of children?
16. Legal guardian of the person?(Yes) (No) Name ______ Permanent home address ______ since (date) Occupation Court appointed at (place) on (date)
17. Why and when did you move your home to North Carolina? (reason) (date)
18. When and from what state or foreign country did you move your home and legal residence to North Carolina? Moved from ___ on (date)
19. When do you claim that you began your legal residence (domicile) in North Carolina? (date) ______
20. Your marital status: single married (date) divorced (date) separated (date) legal separation (date) widowed date) marriage annulled (date)
21. If married, your spouse's name Occupation __ Employer Permanent home address since (date) Last previous permanent home address outside N. C. from (date) to (date) Present legal residence (domicile) is (State) since (date)
22. List in chronological order to date of this application all places you have spent at least 7 consecutive days during the past three years, including vacations and places lived: Place Dates Purpose (from) (to) a) b) c)
If married, list in chronological order to date of this application all places your spouse has spent at least 7 consecutive days during the past three years, including vacations and places lived: Place Dates Purpose (from) (to) a) b) c)
23. Who (including yourself) last claimed you as an exemption on State and/or Federal income tax returns, for what tax year, and in what state filed? a) On State return for tax year, filed in (State) Name Relationship to you
b) On Federal return for tax year, filed in (State) Name Relationship to you
c) Is it the present intention of anyone (including yourself) to claim you as a dependent on State and/or Federal income tax returns for the current tax year? (Yes) (No) If so, who? Relationship to you With respect to tax returns to be filed in what state (s)?
24. Name each state or foreign country (1) where you did any of the following within the last 24 months or (2) if not done in the last 24 months, where such acts were last done. (Provide month, day, and year of each such act; if never done, write "never.") (State or foreign country) (Month/Day/Year) a)Voted b)Registered to vote c)Called to serve on jury duty d)Acquired or renewed driver's license
e)Filed state income tax return (If this was an N.C. return, did you show on this return that you were a NONresident of N.C. for any period of the tax year? yes no. If yes, what period?)
(If this was not an N.C. return, did you show on this return that you were a RESIDENT of N.C. for any period of the tax year? yes no. If yes, what period?) (State or foreign country) (Month/Day/Year)
f) Had state income tax withheld during the current tax year
g) Filed state intangible tax return
h) Listed personal property for taxation
i) Acquired ownership of property for use as your principal dwelling
j) Registered/licensed a motor vehicle (car, truck, or other requiring license) Type of vehicle Where registered/licensed Date (list all)
25. The car(s) or other motor vehicles that you maintain and operate in N.C. are owned by (Name) (Address) Registered/licensed in (state or foreign country )
26. The car(s) or other motor vehicles that you maintain and operate in N.C. are insured in the name of (Address)
27. List the addresses at which you own and maintain personal property (clothing, furniture, cars, boats, savings accounts, pets, jewelry, appliances, etc.) and give percentage value (of total personal property) maintained at each address. Address % at this Address a) b) c)
28. List employment for wages in the last twenty-four months: Employer Address Dates Hours worked (place and state) per week a) b) c) If married, list your spouse's employment for wages in the last 24 months: Employer Address Dates Hours worked (place and state) per week a) b) c)
29. List the sources and uses of the money required to meet your expenses: Source Preceding Calendar Year Current Calendar Year, % of Total Used for % of Total Used for Your earnings, Parent(s) or Guardian, Spouse's earnings, Other (specify)
30. a) Are you now in, or a veteran of, active military service or other Federal government employment? (Yes) (No) If Answer is "yes," Your home address upon entry, Your official home address now, Date this home address was declared, Your official "home of record", Legal residence you most recently claimed on DD Form 2058 (State of Legal Residence Certificate), Date you completed that DD Form 2058, Your address upon discharge, Place to which you were paid mileage upon discharge
b) If you, your spouse, or one or both of your parents are now inactive military service, attach to this application a copy of the "Leave and Earnings Statement" for the most recent pay period and for the pay period 12 months ago, for each such person.
31. If you (1) now live regularly with, (2) have lived with during the immediately preceding 24 months (except for vacation visits of fewer than 7 consecutive days ), or (3) continue to maintain close ties with and periodically live with, another person who is a relative by blood, marriage, or court order or a legal guardian of the person, or (4) have been claimed within the immediately preceding 24 months as a dependent for taxation purposes by someone other than yourself, answer the following for each such person. (Answer only for one adult at each address. If married, complete for spouse; if separation occurred within last 24 months, complete for spouse; if divorce occurred within last 24 months, complete for ex-spouse.)
a) Name, Relationship to you. Permanent home address, Lived at this address since (date), Last previous permanent home address, from (date) ____ to (date)
Is any such person now in, or a veteran of, active military service or other Federal government employment? (Yes) (No), If answer is "yes," provide the following for each such person:, Home address upon entry, Official home address now, Date this home address was declared Official "home of record", Legal residence most recently claimed, Date DD Form 2058 was completed, Address upon discharge, Place to which mileage paid upon discharge
b) Places (states or foreign country) and dates where each of the following acts (1) was performed by each such person within the last 24 months or (2) if not done in the last 24 months, where such person last did each act. (If never done, write "never.") (State or foreign country) (Month/Day/Year), Voted, Registered to vote, Called on jury duty, Acquired driver's license, Filed State income tax return. (If this was an N.C. return, did the taxpayer show on the return that he/she was a NONresident of N.C. for any period of the tax year? yes no. If yes, what period? )
(If this was not an N.C. return, did the taxpayer show on this return that he/she was a RESIDENT of N.C. for any period of the tax year? yes no. If yes, what period? ) (State or foreign country) (Month/Day/Year) Filed state intangible tax return, Listed personal property for taxation, Acquired ownership of property for use as principal dwelling, Inclusive dates of such property ownership, from (date) to (date), (State or foreign country) (Month/Day/Year), Registered/licensed motor vehicle(s), Claimed you as an exemption on State income tax return, Federal income tax return
32. If you are an alien, answer and complete the following appropriately: a) I possess a valid, current visa (Yes) (No) My visa has the designation of .(A,B,C, D,E,F,G,H,I,J,K,L, or M plus a number).
Note. B,C,D,F,H,J, and M visas reflect a presence in the United States not sufficient to support a bona fide claim to North Carolina legal residence.) My visa was issued as of (date).
b) I possess a valid, current Form I-151 or I-551 (Alien Registration Receipt Card). (Yes) (No) .Its Registration Number is ; it reflects my entry into the United States as an immigrant on (date) .
c) I possess a valid, current Form I-181b (Memorandum of Creation of Record of Lawful Permanent Residence). (Yes) (No) It reflects my entry into the United States as an immigrant on (date).
d) Immediately before I received my Form I-151 (or Form I-551or Form I-181b) I possessed a valid current visa. (Yes) (No)This was an immigrant visa. (Yes) (No) This was a visa with letter designation of . My visa was issued as of (date).
e) I possess a valid, current Form I-94 (Arrival-Departure Record) Parole Edition. (Yes) (No) The parole date on the form is .
f) I possess a document issued by Immigration authorities (letter, form, certificate, etc.) that shows that I will later be issued one or more of the documents described above. (Yes) (No) Its effective date is .
Identify (Attach a copy if permitted by Immigration law. If not, be prepared to display the document for inspection upon request.)
g) I possess a document issued by Immigration authorities not identified above that supports my claim to resident tuition status.(Yes) (No) Its effective date is . Identify (Attach a copy if permitted by Immigration law. If not, be prepared to display the document for inspection upon request.)
33. Describe any other circumstances, events, or acts, specifying their place and date, that you feel support your claim to North Carolina residence for tuition purposes.
- - I hereby acknowledge that completion of Item 2 (Social Security number) is voluntary, is requested by the institution solely for administrative convenience and record-keeping accuracy, and is requested only to provide a personal identifier for the internal records of this institution.
- - I hereby certify that all information I have set forth herein is true to the best of my knowledge, pursuant to my reasonable inquiry where needed.
- - I hereby acknowledge that the institution may verify the informationset forth herein from sources accessible under law to the institution but that the institution may divulge the contents of this application only as permitted under the Family Educational Rights and Privacy Act of 1974 if I am, or have been, in attendance at this institution.
Applicant's signature Date
Signature of parent or guardian (if applicant Date is under 18 years of age)
