Fillable Residency Reclassification Request Form (Page 3 of 3) in pdf

Please complete if you are under 25 years of age before the first day of the semester:

Student Financial Independent Status:

Yes No

1. Have or will your parents claim you for tax purposes this calendar year?

Yes No

2. Were you claimed as a dependent for tax purposes within the last two years?

3. Have or will you receive $750 or more in financial assistance from your parents/sponsor this calendar year?Yes No

4. Did you receive $750 or more in financial assistance from your parents/sponsor within the last two years? Yes No

Yes No

5. Have or will you live with your parents for more than six weeks this calendar year?

Yes No

6. Did you live with your parents for more than six weeks at any time within the last two years?

Yes No

7. Are your parents California residents?

If yes, California residents since: _____________________________

8. If your parents are divorced/separated, indicate the state where each parent lives

_____________________________

________________________

Mother

Father

9. Indicate your source of financial support for last year and the current year:

Last year source: _____________________________________________

Current year source: ___________________________________________

Please complete if you are under 19 years of age before the first day of the semester:

Where do you live? Please circle: Both Parents

Mother

Father

Somewhere Else

Are your parents California residents? Yes _____ No ______

If no, indicate the State of residence for each of your parents:

Mother: ____________________ Father: ___________________

Has your mother and/or father lived in CA continuously for the last two years? [Mother Yes No] [Father Yes No]

If no, what day did their present stay in CA begin? [Mother: Date: ____/____/____] [Father: Date: ____/____/____]

If you do not live with either parent, are you under continuous and direct care and control of a court appointed legal

guardian? No ____

Yes _____ If yes:

How long have you been continuously under this person’s direct care and control? _________________________

_____________________________________________________________________________

Student Signature

You must complete, sign, and submit this form with the following: Valid Photo ID and a clear, legible, copy of all documentation provided to be

attached to this form. We may ask to see original documentation. If you have questions about completing this form please contact the Admissions

and Records Office at (707) 527-4685. Please fax to: (707)527-4798 Or: submit in person to: Santa Rosa Junior College, Santa Rosa or Petaluma

Campus, Admissions & Records Office. Or: mail to: Santa Rosa Junior College, 1501 Mendocino Ave., Santa Rosa, CA 95401.

Affidavit: I certify under penalty of perjury that all the information I have given on this form is true and complete to the best of my knowledge. I

understand that falsification or withholding of information requested shall constitute grounds for dismissal. I understand if it is determined I do not

meet the requirements to be classified as a resident, I will be responsible for payment of non-resident fees. I understand that failure to pay these fees

in accordance with the College’s payment policy will result in a hold on my student records for future semesters. I understand that I will be requested

to provide proof of some statements in accordance with Education Code Sections 68040 et seq.

Student Signature: ________________________________Date:____/____/____