Uncg - North Carolina Residency Questionnaire Form Page 3
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4NAME ____________________________________________________________________________________________
PAGE 3
Are your parents separated or divorced?
Yes
No If yes, who has legal custody?
15.
_______________________________
16. Guardian Name (if not living with parents)
_________________________________________________________________________
Current Address
_______________________________________________________________________________________________
(Street)
(
________________________________________________________________________________ Since _____/_____/_____
City, State, Zip)
mo.
day
yr.
Previous Address
______________________________________________________________________________________________
(Street)
(
)_______________________________________________________________
From ____/____/____ Until ____/____/____
City, State, Zip
mo.
day
yr.
mo.
day
yr.
State of Legal Residence
______________________________________________________________ Since (
____/____/____
mo./ day/ yr)
Employer
___________________________________________________________________________________________________________
Occupation
Location
___________________________________________
(City, State) __________________________________________
Highest Education Level Completed (or degree received) ________________________________________________________
Tax Information:
17.
Did you claim yourself as an exemption on income tax returns last year?
A:
(if you filed your own taxes and no one else claimed you, check “yes”)
Yes
No
If “yes,” in what state did you file? ____________________________________________________________________
If someone else claimed you on his/her income taxes, please provide the following information:
B:
Who last claimed you as a dependent or exemption on income tax returns?
Name _______________________________________________________________________________________________
Relationship ______________________________ Tax Year _____________
State filed _______________________
Do you intend to claim yourself as an exemption on income tax returns for the current year?
C:
(if you intend to file your own taxes and no one else will claim you, check “yes”)
Yes
No
If “yes,” in what state do you intend to file? _____________________________________________________________
If someone else intends to claim you as a dependent or exemption on income tax returns for the current year,
D:
please provide the following information:
Name _______________________________________________________________________________________________
Relationship _____________________________ Tax Year ____________
State to be filed ___________________
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