Fillable Application For Admission Form (Page 3 of 3) in pdf

For Office Use Only

APPLICATION FOR VIRGINIA IN-STATE TUITION RATES

TERM_________ Empl.ID_______________

Eligibility for in-state tuition is pursuant to Section 23-7 .4, Code of Virginia. Failure to complete

_______ Staff Initials__________

and return this form to the college will result in an out-of-state classification for tuition purposes.

Date ________________________________

Please contact the admissions and records office at your college if you have any questions.

SECTION A – TO BE COMPLETED BY APPLICANT

SECTION B – PARENT, LEGAL GUARDIAN, OR SPOUSE

1. ___________________________________

______________________________

1. Name of parent, legal guardian, or spouse ________________________________

Print Full Name

SSN

__________________________________________________________________

2. How long have you lived in Virginia? ________________________________________

2. Relationship to applicant: (___) Parent

(___) Legal Guardian

(___) Spouse

3. Citizenship: (__) U.S.

(__) Non-U.S.

(__) Permanent Resident

Date of VISA issue: ____/____/____

Date of VISA expiration: ____/____/____

3. Citizenship: (__) U.S.

(__) Non-U.S.

(__) Permanent Resident

VISA Type _____________________ Must provide documentation to the College.

Date of VISA issue: ____/____/____

Date of VISA expiration: _____/_____/____

VISA Type _____________________ Must provide documentation to the College.

Provide documentation of VISA or Permanent Resident Status to college.

4. Where have you lived for the past two years?

List current address first:

4. How long have you lived in Virginia? ______________________________________

From (mo/yr ) To (mo/yr )

Street Address

City

State

______________________________________________________________________

5. Where have you lived for the past two years?

______________________________________________________________________

List current address first:

______________________________________________________________________

From (mo/yr ) To (mo/yr )

Street Address

City

State

______________________________________________________________________

__________________________________________________________________

YES

__________________________________________________________________

a. Do your parents or legal guardian provide over half of

__________________________________________________________________

your financial support or claim you as a tax dependent?

__________________________________________________________________

If yes, Section B must be completed by your parent or legal guardian.

YES

b. If you are married, do you want to claim eligibility for in-state

Will you have filed a tax return or paid income taxes to any

tuition on your spouse’s domicile?

state other than Virginia during the past twelve months?

If yes, Section B must be completed by your spouse.

If yes, what State?________________________________________

If you are under the age of 24, Section B must be completed by your parent or

For what months? ________________________________________

legal guardian, unless

(check all that apply to you ):

(__) Veteran or active duty member of

(__) Graduate/first professional student

7 .

Will you have claimed the applicant as a dependent for federal

the U.S. Armed Forces

(__) Married

and Virginia income tax purposes prior to the term in which the

(__) Have legal dependents other

(__) Both parents deceased, no

applicant will enroll?

than spouse

adoptive or legal guardian

(__) Ward of the court or were a ward of

Will you have provided over half of the applicant’s financial support?

the court until age 18

YES

9. For the entire twelve months prior to the term in which the applicant will enroll,

7 .

Will you have filed a tax return or paid income taxes to any state

will you have:

other than Virginia during the past twelve months?

a. Been a registered voter in Virginia?

If yes, what State? _______________________________________

b. Held a valid Virginia driver’s license or DMV ID card?

8. For the entire twelve months prior to the term in which you enroll, will you have:

If yes, date issued: _____/_____/_____

a. Filed a tax return or paid income taxes to Virginia on

c. Owned or operated a motor vehicle registered in Virginia?

all earned income?

b. Been a registered voter in Virginia?

10.

a. Are you or any member of your immediate family presently

c. Held a valid Virginia driver’s license or a Virginia DMV ID card?

in the military?

If yes, date issued: ____/____/____

If yes, check:

self

and/or

spouse

d. Owned or operated a motor vehicle registered in Virginia?

b. Will Virginia income taxes have been paid on all military

e. Are you or any member of your immediate family presently

income for the past twelve months prior to the term in which

on active duty?

the applicant will enroll?

If no, go to Question 11.

c. Is Virginia listed on your leave and earnings statement?

a. Will Virginia income taxes have been paid on all military income

If yes, when was it changed to Virginia? ___________________

for the twelve months prior to the term in which you will enroll?

Please attach a copy of your current LES.

b. Is Virginia listed on your leave and earnings statement (LES)?

d. If your answer to Question #10a is yes, will the applicant’s

If yes, when was it changed to Virginia? _____________________

non-military parent have resided in Virginia and claimed the

Please attach a copy of your current LES

applicant as a dependent on Virginia income tax forms, earned

c. If your spouse is in the military and stationed in Virginia pursuant

at least the equivalent of a full-time wage salary, and paid

to orders, will you have resided in Virginia, earned at least the

Virginia income taxes on all taxable income earned in this

equivalent of a full-time wage salary, and paid income taxes to

Commonwealth for at least twelve months prior to the term in

Virginia for at least one year prior to the term in which you will enroll?

which the applicant will enroll?

If yes, please attach Virginia income tax forms and military orders.

If yes, please attach federal and Virginia income tax returns.

10.

Have you been discharged from the U.S. Armed Forces?

If yes, discharge date: __________________________________

1 1. Answer this question only if you live outside Virginia but work in Virginia:

1 1.

Answer this question only if you live outside Virginia, but work inVirginia:

Will you have lived outside Virginia, worked in Virginia, earned

Will you have lived outside Virginia, worked in Virginia, earned at

at least the equivalent of a full-time wage salary, and paid

least the equivalent of a full-time wage salary, and paid Virginia

Virginia income taxes on all taxable income earned in this

income taxes on all taxable income earned in this Commonwealth

Commonwealth for at least twelve months prior to the term

for at least twelve months prior to the term in which you will enroll?

in which the applicant will enroll?

If yes, please attach a copy of your Virginia income tax forms.

I certify under penalty of disciplinary action that all of the information is complete and

accurate. I agree to supply the college with supporting documentation related to my

accurate. I agree to supply the college with supporting documentation related to this

application, if I am requested to do so.

Signature of Parent, Legal Guardian, or Spouse

Date

Signature of Applicant

Date

Application For Admission Form Page 3

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