Domicile Affidavit - Residency Statement
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2Domicile Affidavit – Residency Statement
INSTRUCTIONS: If you will be under the age of 19 or claimed as a dependent, at the start of semester, columns “A” and
“B” are required. The student fills out column “A” and the parent or legal guardian fills out column “B”. Complete the
information in ink, leaving no blanks. Students who do not complete the form or leave information blank may be classified
as a non-resident for tuition purposes. Documentation is required as indicated below or when requested by the College.
1. Full Legal Name (Last, First, Middle)
Fall Spring
Summer
2. For what term are you seeking classification as a resident?
Year:
3. CCC Student ID Number
@__ __ __ __ __ __ __ __ or Comet ID:
4. Social Security Number*
____ ____ ____ - ____ ____ - ____ ____ ____ ____
5. I choose not to disclose my social security number*
Signature:
6. Home Phone Number
(
) ____ ____ ____ - ____ ____ ____ ____
7. Birthdate and Age
Month__________ Day_______ Year_________ Age _________
Yes No
8. Are you seeking admission under the Western Undergraduate
Exchange Program (WUE)?
See explanation below.
(Western Undergraduate Exchange (WUE) Tuition Waiver. Waivers are available for students who live in one of the following states: Alaska,
California, Colorado, Hawaii, Idaho, Montana, Nevada, New Mexico, North Dakota, Oregon, South Dakota, Utah, Washington, Wyoming, and U.S.
Pacific Territories and Freely Associated States. For more information go to: ) or
Legal guardians must be court appointed for purposes
A
B
other than gaining in-state tuition and proof of
Student
Parent or Guardian
guardianship must be attached.
Mother:
or
9. Information for Parent or Guardian
Father:
or
Legal Guardian:
10. Full Legal Name
11. Mailing Address
12. Permanent Address
Source:
Source:
13. What is your source of income (e.g., self, spouse or
Yes No
Yes No
parent) Are you currently employed in Arizona?
If yes, where?
Employer:
Employer:
14. Have you, or will you have, lived continuously in Arizona
Yes No
Yes No
for at least 12 consecutive months immediately prior to
the term you are seeking classification as a resident?
Date:
Date:
Date Arizona residency began?
15. Are you a citizen of the United States?
Yes No
Yes No
a. If no, are you a Permanent Resident Alien card holder?
Yes No
Yes No
(Provide documentation)
b. If no, under what Visa did you enter the United States?
(Provide documentation)
Visa Type:
Visa Type:
Revised 06/24/15
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