2014-2015 Request To Waive Undergraduate Admission Application Fee Form (Page 2 of 2) in pdf

Certification of

United States Citizenship or Immigration Status

Campus

Last Name

First Name

If you are not a U.S. citizen, please check one of the following:

I am a U.S. permanent resident and have a Permanent Resident Card (I-551).

I am a conditional permanent resident (I-151C).

I am a noncitizen with an Arrival-Departure Record (I-94 or I-94A) from the United

States Citizenship and Immigration Services (USCIS) showing one of the following

designations:

(a) “Refugee, ” (b) “Asylum Granted, ” (c) “Parolee, ” or (d) “Cuban-Haitian Entrant. ”

I hold a valid nonimmigrant visa. Please state which visa you hold and its expiration

date:

Visa ___________________

Expiration Date __________

I am a citizen of the Freely Associated States (Federated States of Micronesia, the

Marshall Islands, or Palau).

I am a dependent of a noncitizen classified as NATO-1 through NATO-7.

I am a noncitizen who has been paroled into the U.S. under Section 212(d)(5) of the

Immigration and Nationality Act.

I am a victim (or the dependent of a victim) of human trafficking with a Certification or

Eligibility Letter to that effect.

I am a noncitizen who has been battered or subjected to extreme cruelty in the United

States by my spouse or my parent(s) or a member of my spouse or parent’s family

residing in the same household as me, and I have been approved or have a petition

pending which sets forth a prima facie case of eligibility for an immigrant visa under

certain provisions of the Immigration and Nationality Act.

None of the above.

II.

California Residency Exemption

Check all that apply:

I have or will have attended high school in California for three or more years.

I have or will have graduated from a California high school or have attained a High

School Equivalency Certificate issued by the California State GED Office or a

Certificate of Proficiency, resulting from the California High School Proficiency.

I am without legal immigration status and will fill out an affidavit stating that I have filed or will file

an application to legalize my immigration status as soon as I am eligible to do so.

CERTIFICATION

—To be read and signed by all individuals completing this form.

I certify under penalty of perjury under the laws of the state of California that the information

provided by me on this form is true, complete, and accurate.

__________________________________________________

________________________________

Date

Signature

SAS/July2013

2014-2015 Request To Waive Undergraduate Admission Application Fee Form Page 2

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