Residence Questionnaire Template
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Residence Questionnaire
CSU
(rev. 08/07)
ADDITIONAL INFORMATION IS REQUIRED TO DETERMINE YOUR RESIDENCE STATUS. COMPLETE AND RETURN THIS FORM TO THE
.
CAMPUS OFFICE OF ADMISSIONS AND RECORDS
The information requested is deemed relevant and necessary to a proper determination of your residence status for tuition purposes pursuant to Education Code Section 68041.
Failure to answer all questions may cause you to be classified as a nonresident. You may submit additional information you believe will establish your California residence.
Questions about residence regulations should be referred to a campus residence specialist. A summary of the regulations is printed in campus catalogs and in the application for
admission booklet. If you disagree with the campus residence determination, you have the right to appeal that decision to the Office of General Counsel, The California State
th
University, 401 Golden Shore, 4
Floor, Long Beach, California 90802-4210 within 120 days from the date of the final residence determination by the campus. Note: You may be
requested to furnish documentation in support of your responses.
Name ______________________________________________________________________ Social Security No. _______________________________
Last Name
First
Middle
Birth date _______/_______/_____
Campus _____________________________________ Term applying for __________________/______________
Month
Day
Year
Specify Campus
Term
Year
1.
If you will be 19 years of age or older by the residence determination date, check here and
Residence Determination Dates
○
Quarter Calendars
Semester Calendars
Answer 2 through 16 as they pertain to you.
Fall……….………. September 20
Fall………….…… September 20
Winter…. ..................... January 5
Winter ..……………
January 5
If you will be younger than 19 years of age by the residence determination date, check here and
Spring …………. .............. April 1
(Stanislaus only)
Answer 2 through 16 as they pertain to the natural or adopted parent with whom you most recently
Summer……….……………July 1
Spring …………………January 25
○
resided and whose name and whereabouts you will provide below.
Summer……….……………June 1
CalState TEACH
Name/Relationship _____________________________________________________________
Stage 1 ..………….September 20
Stage 3 ……………….…….June 1
Stage 2 ..………………January 5
Stage 4 ……………..September 20
Present actual whereabouts ______________________________________________________
2. What State do you regard as your permanent home? ________________________
3. If California, when did your present stay begin? _____/_____/_____
Month Day Year
○
○
4. Are you claimed as a dependent on the military record of any member of the U.S. armed forces? Yes
No
If “yes,” explain the relationship and answer #6 for the service person.
○
○
5. Member or veteran of U.S. armed forces? Yes
No
Date joined _____________ From what state ______________ Date separated from active duty, if any _______________
6. Most recent permanent address on military records_____________________________________________________________________________________________
Stationed ____________________________________________________________________ From ___________________ To ____________________________
○
○
7. Have you ever registered to vote? Yes
No
State ________________
Date registered _____/_____/_____
Last Voted _____/_____/_____
List all states where registered and date of registration
Month Day Year
Month Day Year
State ________________
Date registered _____/_____/_____
Last Voted _____/_____/_____
Month Day Year
Month Day Year
○
○
8 Do you possess a driver’s license and/ or ID Card?
Yes
No
If yes:
State ______
Date issued
_____/_____/_____
Day Year
Previous State ______
Date issued
_____/_____/_____
Month Day Year
9. Current registration of all vehicles owned or operated in CA
State ______ Date issued
_____/_____/_____
State ______
Date Issued _____/_____/_____
Month Day Year
Month Day Year
○
○
10.
Are all personal effects located in California? Yes
No
If “no,” attach explanation on a separate piece of paper.
11.
Purchase date(s) and location(s) of California residence(s) owned
Date _____/____/____
Location ____________________________________________________________
Month Day Year
Date _____/____/____
Location ____________________________________________________________
Month Day Year
12.
Purchase date(s) and location(s) of other residence(s) owned
Date _____/____/____
Location ___________________________________________________________
Month Day Year
○
○
13.
Did you attend a California High School for at least 3 years and graduate or obtain a California G.E.D?
Yes
No
○
○
14.
Employed in California in the past year? Yes
No
Employer(s) _______________________________________________ From _____/_____/_____
To _____/_____/_____
Month Day Year
Month Day Year
15.
State where last three state income tax returns filed on total income and year covered by each.
State _____ Year _____
State _____ Year _____
State _____ Year ____
16.
Address shown on most current W-2 form ____________________________________________________________________________________________________________________
Certification – To be read and signed by all applicants to certify the accuracy of the information provided.
I certify under penalty of perjury that the foregoing statements and any other information submitted by me in connection with the determination of my residence are true, complete, and accurate.
I certify that so long as I am a student at this institution, I will advise the residence specialist if there is a change in any of the facts upon which the residence determination was made, such as the
state of residence and military status of my parent if I am a minor or, if not, changes in any of the above for me or my spouse, if any; changes in the California State University employment status of
my spouse, parent, or myself; or changes in my teaching employment or credential status. I authorize release of any information submitted by me in connection with my application for admission
and determination of residence to any person, firm, corporation, association or government, whether federal, state, local, or foreign, but only as necessary to verify or explain the information, to
obtain pertinent records, or in connection with perjury proceedings.
Signed at _____________________________________________________________________________________________________________________________________________
City and County
Applicant’s Signature
Date
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