Basic Residence Questionnaire Supplement Part I
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2BASIC RESIDENCE QUESTIONNAIRE SUPPLEMENT
NAME _________________________________________________
SSN or SCCID# ________________________
(Please Print)
Last
First
M
DATE OF BIRTH __________________________________ PHONE # _______________________________________
Unless you have been a resident of California for at least one year and one day prior to the beginning of the semester you
wish to enroll in, you must pay non-resident tuition.
Please complete this questionnaire if you would like your
residency status to be re-evaluated.
Attach proof of intent to become a resident (i.e., rent receipts – to prove most recent day present stay began in California,
leave and earnings statements if active duty military, driver’s license, vehicle registration and most recent California 540
tax form.)
PART I
(To be completed by all students)
____________________________________________
A. Date your present stay began in California
B. List where last two state income tax returns were filed and year covered by each (attach copy of most recent
state income tax return)
___________________________________________________________________________
State
Year
State
Year
If no taxes were filed, explain:
__________________________________________________________________________________________
C. From what state do you have any of the following?
Driver’s License
State
___________________________
Vehicle Registration
State
___________________________
Registered to Vote
State
___________________________
Other Proof of Residency in California:
__________________________________________________________________________________________
D. Are you unmarried and under 19 years of age?
_____ YES
_____ NO
(If YES, complete Part III concerning your parents.)
PART II
(To be completed by military personnel and their dependents only)
A. Are you an active member of the military?
_____ YES
_____ NO
B. Are you a dependent of an active duty military person?
_____ YES
_____ NO
C. What is your or your sponsors’ (spouse or parents if military dependent) state of legal residence on military
records?
_____________________________________
Date established:
_____________________________________
Active Duty Military: Attach a copy of your most recent LES (Leave and Earnings statement) and an LES from
one year ago.
SEE REVERSE SIDE – COMPLETE INFORMATION ON BACK OF THIS SHEET.
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