Basic Residence Questionnaire Supplement Part I (Page 2 of 2) in pdf

Basic Residence Questionnaire Supplement Part I Page 2

PART III

(To be completed about your parents if you are unmarried and under 19 years old)

I have lived continuously for the past two (2) years with one or both of my parents and he/she/they have

lived continuously for the past two (2) years at the California address noted below.

_____ YES

_____ NO

If YES, check one: Both parents_____ Mother_____Father_____

Names (s) _________________________________ Address ______________________________________

City/State/Zip _____________________________________

List where parents’ last two state income tax returns were filed and year covered by each (attach copy of

parents most recent state income tax return.)

State ________________________________ Year _______________

If no taxes were filed, explain: ______________________________________________________________________

Do your parents have any of the following:

FATHER

MOTHER

Driver’s License

State: ______________

Vehicle Registration

State: ______________

Registered to Vote

State: ______________

Other Proof of Residency in California: _____________________________________________________________

* * *

A L L

S T U D E N T S

* * *

I declare under penalty of perjury that the statements submitted by me in connection with the

determination of my residency are true and correct, and I will notify the Office of Admissions

and Records if there is any change in any of the facts regarding my residency.

Executed at:

________________________________________________

Date:

________________________________________________

Student’s Signature: ______________________________________________

OAdmissions and RecordsFormsBasic Residence Questionnaire Supplement1 07

Basic Residence Questionnaire Supplement Part I Page 2