Regional Residency Form - University Of Baltimore
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1
2REGIONAL RESIDENCY FORM
IN-STATE TUITION STATUS
graduate students only *
_____________________________________________________________________________________________________________
If you are a resident of the District of Columbia, Northern Virginia (Arlington, Loudoun, Fairfax and Prince William counties
and Alexandria, Fairfax, Falls Church, Manassas and Manassas Park), Pennsylvania (Adams, York and Lancaster counties)
and Delaware (all counties) you may apply for a regional residency determination.
Name: _____________________________________________________________ Date of birth: ________________
Email: _______________________ Home phone number: _________________ Cell: _________________________
Is your permanent residence in one of the areas listed above?
Yes
No
Permanent Address: _______________________________________________________________________________
street
city
state/province
zip
How long have you lived at your permanent address? Years: _____Months: _____
Previous Address: __________________________________________________________________________________
street
city
state/province
zip
How long did you live at your previous address?
Years: ____ Months: _____
PLEASE CHECK ONE:
I am financially independent. I have earned taxable income and I have not been claimed as a dependent on another
person’s most recent income tax returns.
a. Have you filed a state tax return in the most recent tax year in any of the following states/districts?
DC, DE, PA, VA?
Yes
No
b. Please list the years you filed a state return in the above state/districts in the last two years:
__________________________________________________________________________________
c. Please state any reasons for not filing in one of the following states/districts (DC, DE, PA, VA) in the last
12 months: _______________________________________________________________________
_________________________________________________________________________________
d. Is income tax being withheld from DC, DE, PA or VA from your pay?
Yes
No
e. Did you receive any public assistance from any agency not in DC, DE, PA or VA?
Yes
No
I am financially dependent. Another person has or will claim me as a dependent on his/her most recent income tax
returns.
a. Name of person upon whom dependent and relationship: __________________________________
__________________________________________________________________________________
b. How long have you been dependent upon this person? _____________________________________
I am a ward of the State.
*Regional residency only applies to students and credits associated with a UB graduate program. Undergraduate degrees
and certificates, doctoral, law and advanced professional degrees are not included.
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