Application For Classification As A Legal Resident - Wayne Community College Page 3

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18.

If you (1) now live regularly with, (2) have lived with during the immediately preceding 24 months, or (3) continue to maintain close ties with and

periodically live with, another person (who is a relative by blood, marriage, or court order or a legal guardian of the person) answer the

following such person. (Answer only for one adult person at each address. If married, complete for spouse; if separation occurred within last

24 months, complete for spouse; if divorce occurred within last 24 months, complete for ex-spouse. If parents, complete for head of household.)

a) Name(s) ______________________________________________________ Relationship to you ____________________________________

Permanent home address _______________________________________________________________________ Lived at this address

since (date) ______________ Last previous permanent home address ________________________________________________________

from (date) ____________ to (date) ______________. Is any such person now in, or a veteran of, active military service or other Federal

government employment?

Yes

If answer is “yes,” give Home address upon entry ___________________________________

_________________________________________________________________________________________________________________

Ofﬁ cial home address now ________________________________________________ Date this address declared ____________________

Legal residence most recently claimed on DD Form 2058 (State of Legal Residence Certiﬁ cate) ____________________________________

Date that DD Form 2058 was completed ________________________________________________________________________________

Home address upon discharge ___________________________________________________ Date of discharge _____________________

b) Place (state or foreign country) and date each time each of the following acts were performed by each such person within last 24 months

(or if not done in the last 24 months, where and when such acts were done last; if never done at all, write “never”).

(State[s])

(Month / Day / Year)

1) Voted ________________________________________________________

__________________

________________________

2) Registered to vote ______________________________________________

__________________

________________________

3) Served on jury duty _____________________________________________

__________________

________________________

4) Acquired driver’s license _________________________________________

__________________

________________________

5) Filed state income tax return ______________________________________

__________________

________________________

6) Filed state intangible tax return ____________________________________

__________________

________________________

7) Listed personal property for taxation ________________________________

__________________

________________________

8) Acquired property for use as principal dwelling ________________________

__________________

________________________

9) Inclusive dates of such property ownership: from (date) _____________________________ to (date) ____________________________

10) Registered/licensed a motor vehicle(s) ______________________________

__________________

________________________

11) Claimed you as an exemption on

State[s])

State income tax return _________________________________________________for tax year ___________________________

Federal income tax return_______________________________________________ for tax year ___________________________

19.

Are you an alien (not a United States citizen)?

Yes

No. If yes, additional information concerning your visa will be requested.

20.

If there are additional circumstances, events, or acts that you feel support your claim to North Carolina legal residence (domicile) for tuition

purpose, describe each, specifying the place and date of its occurrence:

I hereby certify that all information I have set forth herein is true to the best of my knowledge, pursuant to my reasonable inquiry where needed.

I hereby acknowledge that the institution may verify the information set forth herein from sources accessible under law to the institution but that

the institution may divulge the contents of this application only as permitted under the Family Educational Rights and Privacy Act of 1974 if I am, or have

been, in attendance at this institution.

_____________________________________

__________________________________________________________

_____________________

Signature of applicant

Signature of parent or guardian also, if applicant is under 18 years of age

Date

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