Application For Clasification As A Legal Resident (Domiciliary) Of North Carolina For Tuition Purposes (Long Form) (Page 4 of 4) in pdf

24. a) Have you, your spouse, or either of your parents been in active military service within the past two years?

Yes __________ 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, your spouse, 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 completed _____________

Place to which mileage was paid upon discharge _______________________________

State for which income tax was withheld _________________________ From what date? _______________

25. 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 your parents are separated or divorced, answer this

question for both parents.

---- Your spouse, estranged spouse (if separation occurred within the past 24 months), or ex-spouse (if divorce

occurred within the past 24 months).

---- 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 not done in the last 24 months, where and when did he or she

do these acts last? If never done at all, write “never”):

Place/Month/Day/Year

1) Registered to vote

__________________

___________________

2) Voted

__________________

___________________

3) Called to serve on jury duty

__________________

___________________

4) Acquired/renewed driver’s license ________________

___________________

5) Acquired ownership of property

to use as your principal dwelling __________________

___________________

6) Inclusive dates of property ownership: from _______ to _______ from _______ to _______ from ______ to ____

7) Filed state intangible tax return __________________

___________________

8) Filed state income tax return

__________________

___________________

9) Listed personal property for taxation ________________ ___________________

___________________

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) _________________

26. 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.

_________________________________________ __________________

_____________________________

Signature of applicant

Date

Signature of parent or guardian

if applicant under 18 years of age

Application For Clasification As A Legal Resident (Domiciliary) Of North Carolina For Tuition Purposes (Long Form) Page 4

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