Arkansas Tax Waiver Non Resident Form

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ARKANSAS TAXPAYERS
WAIVER OF NON-RESIDENT
I, _____________________________________________________, ________________________________________
(Print Name)
(Student ID Number)
hereby request waiver of non-resident (out-of-state) fees for the school year ______________________________________.
Check one:
Semester: Fall __________ Spring __________ Summer: 1st Term __________ 2nd Term __________.
In order to get the non-resident fee waived, the following criteria must be met:
1.)
Dependent student or parent must provide a W-2 or verification of Arkansas Earnings of $5,500.00 or more dollars
from the year preceding enrollment.
2.)
Student and parent must live in one of the following:
Missouri
Oklahoma
Texas
Louisiana
Barry
Bowie
Claiborne Parish
Adair
Morehouse Parish
Dunklin
McDonald
Deleware
Union Parish
Oregon
LeFlore
Webster Parish
Ozark
McCurtain
Mississippi
Pemiscot
Sequoyah
Ripley
Bolivar
Taney
Tennessee
Coahoma
Dyer
Desota
Lauderdale
Tunica
Shelby
Tipton
I certify that the dependent child is unmarried and age 23 or younger and has been claimed by me for income tax purposes in the
preceding year and will be claimed by me during the time of the tuition waiver. If the child was not claimed by me in the preceding
year, the child was claimed by the child’s other parent and will be claimed by me in the year of the waiver.
Signature ___________________________________________________ Date _________________________________
Name of Parent ___________________________________________________________________________________
Adddress _________________________________________________________________________________________
Phone Number ____________________________________________________________________________________
This form must be submitted each time you enroll at SAU.
Office Use Only
Business Office authorization _____________________
Date ________________________________________
Amount _____________________________________

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