Minnesota State Grant Questionnaire Template Page 2
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2SECTION E. Verification of student’s Minnesota residency (all students must complete)
1. Have you maintained continuous residency in the state of Minnesota since birth?
yes
no
If no, in which state or country did you live prior to residency in Minnesota? _______________________ Dates: _________ to _________.
2. Dates you have resided in Minnesota (mm/dd/yyyy): from _______________________ to _________________________.
3. Dates you have resided at the address given on this form (mm/dd/yyyy): from _______________________ to _________________________.
4. Date you became at least a half-time student at a Minnesota post-secondary institution (mm/yyyy): ______________.
5. Have you ever received a Minnesota State Grant?
If yes, at which institution? _________________________________________________________________________________.
6. Address at which you resided during your high school attendance:
Street address
City
State
ZIP code
SECTION F.
Military or Missionary service history (please complete if applicable to you and your family)
1. Is a member of your immediate family currently engaged in active federal military service in the state of Minnesota?
self
Date of commencement of service (mm/dd/yyyy): ______________.
spouse
Date of commencement of service (mm/dd/yyyy): ______________.
parent
Date of commencement of service (mm/dd/yyyy): ______________.
none of the above
2. Has a member of your immediate family ever been a member of the U.S. military or a missionary service?
self
Military
Missionary
Date of commencement of service (mm/dd/yyyy): ______________.
spouse
Military
Missionary
Date of commencement of service (mm/dd/yyyy): ______________.
parent
Military
Missionary
Date of commencement of service (mm/dd/yyyy): ______________.
none of the above
3. Were you, your parent, or your spouse a resident of Minnesota prior to entering military or missionary service?
yes
no
4. If you withdrew from college during a term because you were called to active military service after December 31, 2002, please note here and
provide our office with the necessary documentation of this service.
Name of post-secondary school attended prior to active duty
Last term and year before withdrawal
SECTION G. Signature
I understand that I may be asked to provide documents to prove any information recorded on this form. I certify that the above information is true and
complete.
Student signature
Date
FA679—Page 2 of 2
10/14
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