North Carolina Residence & Tuition Status Application Form (Page 4 of 4) in pdf

Where/Month/Day/Year Where/Month/Day/Year Where/Month/Day/Year

1) Registered to vote

___________________ ____________________ ___________________

2) Voted

___________________ ____________________ ___________________

3) Called to serve on jury duty

___________________ ____________________ ___________________

4) Acquired or renewed driver’s

License

___________________ ____________________ ___________________

5) Aquired ownership of property

for use as your principal dwelling ___________________ ____________________ ___________________

6) Inclusive dates of such property

ownership

from: ______to:______

7) Filed state intangibles tax return

___________________ ____________________ ___________________

8) Listed personal property for

taxation

___________________ ____________________ ___________________

9) Filed state income tax return

Did you file as a resident or

nonresident?

___________________ ____________________ ___________________

10) Registered/licensed motor

vehicle(s)

____________________ ___________________ _____________________

11) Claimed you as an exemption on state income tax return for __________ tax year, filed in (state) __________

on (date) ________________; federal income tax return for __________ tax year, filed in (state)____________

on (date)___________________

27. If there are additional circumstances, events, or acts that you feel support your claim to North Carolina legal

residence (domicile) for tuition purposes, attach a description of each, specifying the place and date of its

occurrence.

■

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 information set 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 is under 18 years of age)

Date

North Carolina Residence & Tuition Status Application Form Page 4

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