Certificate Of Residency - Idaho Association Of Counties Page 2
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1
2C
R
ERTIFICATE OF
ESIDENCY
Type of Student:
Assistance is requested from:
County.
Student's Grade Level:
Enrollment Date:
School Providing Course(s)/Dual Credit(s): (check all that apply)
Idaho EDUID #:
College Student ID #:
□
□
□
College of Southern Idaho
College of Western Idaho
North Idaho College
Last Name:
First Name:
M.I.
Phone #: (numbers only)
Maiden Name (if married):
Birth Date (mm/dd/yyyy):
Current Academic Year:
SSN: (numbers only)
High School Last Attended
(high school students only)
Email address:
Current Mailing Address:
Current Physical Address: (if different than mailing address)
______________________________County:_____________
______________________________County:_____________
City:__________________ State: ____________ Zip: ______
City:__________________ State: ____________ Zip:______
Idaho
Idaho
Previous Physical Address: (if different)
Previous Mailing address:
______________________________County:_____________
______________________________County:_____________
City:__________________ State: ____________ Zip:______
City:__________________ State: ____________ Zip: ______
Idaho
Idaho
Dates of Residency at Current Address:
Dates of Residency at Previous Address:
to current.
to
Parent/Guardian Last Name:
Parent/Guardian First Name:
M.I.
Phone #: (numbers only)
Parent/Guardian Email address:
Current Parent/Guardian Mailing Address:
Current Parent/Guardian Physical Address: (if different)
______________________________County:_____________
______________________________County:_____________
City:__________________ State: ____________ Zip: ______
City:__________________ State: ____________ Zip: ______
Idaho
Idaho
Dates of Residency at This Address:
to current.
□
(Check and complete all that apply)
I am on active military orders and am stationed at
□
I am a registered voter in ____________________ County.
________________________________ and residing in
□
My vehicle is registered in ___________________ County.
_____________ County. (Please attach copy of orders)
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My license plate number is: ________________________.
I was honorably discharged after serving 2 years and
□
designated _______________ County as my residence.
My parent(s) or court-appointed guardian(s) have lived in
(Please attach copy of your DD214 form)
_________________ County for at least 12 consecutive
□
I am a resident of ________________ County, but have
months prior to the start of the term in which I am enrolling.
□
been living in another county for less than 1 year and
My parent(s) or court-appointed guardian(s) provide more than
have not established residency.
50% of my financial support.
□
□
I have received or am receiving tuition assistance from
I provide more than 50% of my support and have lived in
_________________ County for at least 12 consecutive months
another county. (List all counties and dates below)
_____________________________________________
prior to the start of this term. (continued in next column
)
I have attached a copy of at least ONE of the following to prove my residency in this county (check all that apply):
□
□
▪ For the student :
Other: ____________________________________
The student’s government-issued identification
▪ Student’s parent/court-appointed guardian (required if student is a minor):
□
□
Student's parent/court-appointed guardian government-issued identification
Other: ___________________________
I certify that all statements I have made in this Certificate of Residency are complete, true and correct.
________
________
Parent or Court-Appointed Guardian’s Signature: (required if student is a minor)
Student’s Signature:
X
X
Date:
Date:
For County Use Only Below this Line
□
□
This Certificate of Residency has been:
Approved
Denied
□
□
□
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Reason, if denied:
Non-residency
Lifetime limit met
Incomplete application
Other: _________________________
By: ______________________________________ Attest: __________________________________ Date:________________________
Rev. 2016-08-30
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