Domicile Affidavit Dependent - Glendale Community College Page 2
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2DOMICILE AFFIDAVIT
To Be Completed By Parent of Dependent Student
Residency for tuition purposes is determined in accordance with state law (A.R.S. §15-1801 et. sec.) and regulations of the Maricopa Community
Colleges Governing Board. All of the Maricopa Community Colleges are subject to the above statutes and regulations. Students who have ques-
tions about their residency should contact the Offi ce of Admissions and Records for clarifi cation.
The responsibility of registration under the proper residency classifi cation is placed upon the student. Any student who is found to be classifi ed
improperly shall be required to pay full out-of-state tuition. In determining a student’s classifi cation, the college may consider all evidence, written
or oral, presented by the student and any other information received from any source which is relevant to determining classifi cation. The college
may request written sworn statements or sworn testimony of the student. Furnishing false information to any offi cial, college employee or offi ce
is a violation of the Student Code of Conduct (AR 2.5.2) and subject to disciplinary sanctions.
(Please print or type: additional information may be submitted)
ALL QUESTIONS BELOW PERTAIN TO THE PARENT.
Name of Parent _______________________________________________ Soc. Sec # __________________________________________
Address __________________________________________________________________________________________________________
Home Phone# ________________________________________________ Work Phone# ________________________________________
When did your current residency in Arizona begin? ________________________________________________________________________
Are you registered to vote in Arizona?
Are you registered to vote in Arizona?
Are you registered to vote in Arizona?
Are you registered to vote in Arizona?
Are you registered to vote in Arizona?
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
County ________________Date registered______________________________
List employers during the past two years:
Employer__________________________________________
Employer_____________________________________________
Place of employment_________________________________
Place of employment____________________________________
Dates of employment: ____/_____/____ to ____/_____/_____
Dates of employment: _____/_____/_____ to ____/______/_____
mm
dd
yyyy
mm
dd
yyyy
mm
dd
yyyy
mm
dd
yyyy
Did your employer require that you or your spouse be transferred to Arizona?
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If yes, provide name of employer ___________________________________________________________________
If yes, provide name of employer ___________________________________________________________________
If yes, provide name of employer
If yes, provide name of employer
If yes, provide name of employer
If yes, provide name of employer
If yes, provide name of employer
If yes, provide name of employer
If yes, provide name of employer
State Income tax-fi led for past two years:
Tax year __________________________________________
Tax year __________________________________________
Tax year
Tax year _____________________________________________
Tax year _____________________________________________
Tax year
State fi led____________________________________________
State fi led ____________________________________________
Address given_________________________________________
Address given_________________________________________
Address given_________________________________________
Address given_ ________________________________________
Address given_ ________________________________________
Address given_
Residence listed_______________________________________
Residence listed _______________________________________
Current driver's license number_________________________ ___
Current driver's license number_________________________ ___
Current driver's license number_________________________
State issued __________________________________________
Date issued _________________ Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If yes, original date issued ____________________________________
If yes, original date issued
If yes, original date issued
If yes, original date issued
If yes, original date issued
If yes, original date issued
If yes, original date issued
Vehicle license number_______________________________
Vehicle license number_______________________________
Vehicle license number_______________________________
State registered_____________________________________ __
State registered_____________________________________ __
State registered_____________________________________
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Date issue
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
Renewal:
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
Vehicle owned by you?
No
No
No
No
No
No
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Are you in the military service?
Are you in the military service?
Are you in the military service?
Are you in the military service?
Are you in the military service?
Are you in the military service?
Are you in the military service?
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If yes, where are you stationed? ____________________________________________
If yes, where are you stationed?
If yes, where are you stationed?
If yes, where are you stationed?
If yes, where are you stationed?
If yes, where are you stationed?
If yes, where are you stationed?
Are you a military dependent?
Are you a military dependent?
Are you a military dependent?
Are you a military dependent?
Are you a military dependent?
Are you a military dependent?
Are you a military dependent?
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If yes, where is your spouse stationed? _______________________________________
If yes, where is your spouse stationed?
If yes, where is your spouse stationed?
If yes, where is your spouse stationed?
If yes, where is your spouse stationed?
If yes, where is your spouse stationed?
If yes, where is your spouse stationed?
Are you a resident member of an Indian tribe whose reservation land lies in this state and extends into another state?
No
No
No
No
No
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
If yes, which reservation _____________________________________________________________________________
If yes, which reservation
If yes, which reservation
If yes, which reservation
If yes, which reservation
If yes, which reservation
If yes, which reservation
I certify that I meet the conditions stated above. I understand that falsifi cation of information is a violation of the Student Disciplinary Code (AR
2.5.2) and my son or daughter may be subject to disciplinary sanctions and the assessment of out-of-state tuition for the period of time for which
the domicile requirements were not fulfi lled.
Approved __ Denied ____
Date _____________
_______________________________________
______________________
College signature____________________________
Parent's signature
Date
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