Fillable Residency Change Form (Page 2 of 2) in pdf

I certify that all statements I have made and documents I have attached in this application are complete and true.

North Idaho College or the State of Idaho are hereby authorized to verify the above information if deemed

necessary. I acknowledge that submitting inaccurate information may result in dismissal from North Idaho College

and that I will be required to repay the full amount of tuition assistance received.

____________________________________________________

_________

Student Signature

Date

I am claiming residency through my spouse, parent or legal guardian. (Completed by Parent, Legal

Guardian or Spouse) Please attach documentation that demonstrates that you have resided in Kootenai County

Idaho for 12 months prior to the beginning of the term. (May include rent/mortgage payment, pay stubs, utility

bills, bank statements, voter registration). Also please include a copy of your driver’s license.

Name_______________________________________________ Relationship to Student_____________________

Last

First

Permanent

Address_____________________________________________________________________________________

Phone Number___________________________

Date of arrival in Idaho/Kootenai County_______________

Please list your residence for the last 12 months

From_________ To________ Address_____________________________________________________________

Please list your employment for the last 12 months

From_________ To________ Employer/address_____________________________________________________

Do you have a driver’s license?

yes

From which state? _______________

I have attached a copy of my license.

What percent of support do you provide for your dependent? ________%

I certify that all statements I have made and documents I have attached in this application are complete and true. North Idaho

College or the State of Idaho are hereby authorized to verify the above information if deemed necessary. I acknowledge that

submitting inaccurate information may result in dismissal from North Idaho College for the student and that the student will be

required to repay the full amount of tuition assistance received.

________________________________________________________________________ _________

Parent/Guardian/Spouse Signature

Date

All Petitions must include a copy of your Idaho driver’s license and 3 items showing 12 months of

physical residence in Kootenai County. These items may include:

Vehicle Registration

Utility Bills

Voters Registration

Military Separation (DD-214

Rent or Mortgage Payments

Banking Statement

Office Use Only:

Approved

Not Approved

Date:

Submit to:

Office of Admissions

1000 West Garden Ave

Coeur d’Alene, ID 83814

Phone: (208)769-3311 Fax: (208)769-3399

Residency Change Form Page 2

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