North Carolina Residence & Tuition Status Application Form Page 2
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4Permanent home address__________________________________________________
Since ___________________
Court appointed at (place) _________________________________________________ (On date) ________________
18. Who (including yourself) last claimed you as an exemption on state and/or federal income tax returns, for what
year, and in what state filed?
(a) On State tax return for ________ tax year, filed in (state)__________ on (date) ____________________________
Name ______________________________________ Relationship to you ___________________________________
(b) On Federal tax return _________ tax year, filed in (state)__________ on (date) ____________________________
Name ______________________________________ Relationship to you ___________________________________
(c) Does anyone intend to claim you as a dependent on state and/or federal income tax returns for the current tax
year? (Yes or No) _________
19. List in chronological order to date of this application all places you have spent at least 7 consecutive days during the
past three years. Your response must include your current address, all other places lived, and vacations.
Place (city and state)
Occupation or Purpose
From (date)
To (date)
a) _________________________
____________________________
______________
______________
b) _________________________
____________________________
______________
______________
c) _________________________
____________________________
______________
______________
20. When and where (state or foreign country) did you do each of the following during the last 24 months?
List each time you did each such act (If not done in the last 24 months, list where and when such acts were done the
last time you did them; if never done at all, write “never”):
Where/Month/Day/Year Where/Month/Day/Year Where/Month/Day/Year
a) Registered to vote
___________________ ____________________ ___________________
b) Voted
___________________ ____________________ ___________________
c) Called to serve on jury duty
___________________ ____________________ ___________________
d) Acquired or renewed driver’s license ___________________ ____________________ ___________________
e) Acquired ownership of property for
use as your principle dwelling
___________________ ____________________ __________________
f)
Inclusive dates of such property
ownership:
from: ______to:_____
from: ______to:_____
from: ______to:______
g) Filed state intangibles tax return
___________________ ____________________ ___________________
h) Listed personal property for
taxation in the county where you live
___________________ ____________________ ___________________
i)
Filed state income tax return
Did you file as a resident or
nonresident?
___________________ ____________________ ___________________
j)
Had state income tax withheld
during the current tax year?
_______ Yes _______ No
State(s) _______________________________
Beginning (Month/Day/Year)
__________________
During the previous year? _____ Yes _____ No State(s) _____________ Beginning (Month/Day/Year)_______
Was all of the amount withheld refunded to you? ______ YES _______ No
(k) Registered/licensed a motor vehicle (car, truck, or other requiring license):
Type of Vehicle (list all)
where registered/licensed
(Month/Day/Year)
________________________
____________________________
____________________
________________________
____________________________
____________________
21. The car(s) or other motor vehicles you maintain and operate in N.C. are owned by
(Name)__________________________________ (address) ___________________________________________
Registered/licensed in (state or foreign country) ________ insured in the name of
________________________________________ (address) ___________________________________________
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