North Carolina Residence & Tuition Status Application Form Page 3
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422. List the addresses at which you own and maintain personal property (clothing, furniture, cars, boats, checking or
savings accounts, stocks, bonds, pets, jewelry, appliances, etc.) and give percentage of value (of total personal
property) maintained at each address:
Address
% at this Address
(a) _______________________________________________________
___________________
(b) _______________________________________________________
___________________
23. List your employment for wages in the last 24 months:
Job title
Employer
Address (place & state)
Dates
Hrs. per week
(from)
(to)
(a) _________________
_________________
_________________
________
_______
____________
(b) _________________
_________________
_________________
________
_______
____________
(c) _________________
_________________
_________________
________
_______
____________
24. Of the total money required to meet your expenses, what percentage came from each of the following sources and
what was it used for?
Preceding Calendar Year (Jan.-Dec._____) Current Calendar Year (Jan.-Dec.____)
Source
% of Total
Used For
% of Total
Used For
Your earnings
_________
_________________
_________
_________________
Your savings
_________
_________________
_________
_________________
Parent(s) or
Guardian
_________
_________________
_________
_________________
Name_____________________________________________________________________________________
Other (specify)_____________
_________
_________________
_________
_________________
Total
100%
_________________
100%
_________________
25. (a) Have you or either of your parents been in active military service within the past two years? (Yes or No)
_________ If so, for each such person, ATTACH copies of the “Leave and Earnings Statements” for the most recent
pay period and for the pay period 12 months ago.
(b) If you or either of your parents have been in active military service or other federal government employment
within the past two years, answer the following for each such person:
Name(s)_________________Relationship to you_________________ Home address upon entry__________________
_____________________________ Official “home of record”________________________ Official home address
now __________________________________________ Date this home address was declared ____________________
Home address upon discharge______________________________________ Date of discharge___________________
Legal residence most recently claimed on DD Form 2058 (State of Legal Residence Certificate) __________________
Date that DD Form 2058 was completed __________________________________ Place to which mileage was paid
upon discharge __________________ State for which income tax withheld ____________ From what date?________
26. Answer the questions below for each of the following individuals:
Your parents (or legal guardian) if you now live with them or have lived with them in the past 24 months
OR if they have claimed you as a dependent for tax purposes in the past 24 months.
Answer this question for your father unless your parents are separated or divorced. If you parents are
separated or divorced, answer this question for both parents.
Any other person who has claimed you as a dependent for tax purposes within the past 24 months.
a) Name(s)_________________________________________ Relationship to you ________________________
Permanent home address ____________________________________________________________________
Lived at this address since (date) ______________________ Last previous home address_______________
______________________________ from (date) _______________________ to (date) __________________
b) Where (state or foreign country) and when did this person do each of the following during the last 24
months? List each time he or she did each such act. (If done in the last 24 months, where and when did
he or she do these acts last? If never done at all, write “never”):
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