Application For Reciprocity Benefits Page 4
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414. List colleges that you previously attended, or are currently attending, and the dates of enrollment (from MM/DD/YY to MM/DD/YY), and
enrollment level (less than half-time or half-time or more) at each institution on the back of this application form.
15. Did you receive reciprocity in any prior years?
( ) NO ( ) YES
If YES, name of institution __________________________________________ from ___/___/___ to ___/___/___
16. Were you or will you be claimed as a dependent?
a. On parent or guardian(s) 2013 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
b. On parent or guardian(s) 2014 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
17. Did you or will you claim yourself?
a. On your 2013 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
NO ( ) YES ( )
If yes, what state? _____________________
b. On your 2014 Federal/State Income Tax?
18. What was your status in 2013?
NO ( ) YES ( ) If yes, dates employed _______________________________
a. Employed?
b. Full-time Student?
NO ( ) YES ( ) If yes, institution ____________________________________
c. Part-time Student?
NO ( ) YES ( ) If yes, institution ____________________________________
NO ( ) YES ( ) If yes, institution ____________________________________
d. Graduate Assistant?
e. Other?
NO ( ) YES ( ) If yes, explain ______________________________________
THIS APPLICATION MUST BE COMPLETED IN FULL AND SIGNED BY THE APPLICANT. IF THE APPLICATION IS NOT
COMPLETE, IT WILL BE RETURNED TO THE APPLICANT FOR COMPLETION. THE APPLICATION MUST BE
SUBMITTED TO THE APPROPRIATE AGENCY BY THE DEADLINE IN ORDER TO BE CONSIDERED. See instruction
sheet for information regarding deadlines.
CERTIFICATION
I HAVE READ THE INSTRUCTIONS ON THE ATTACHMENT TO THIS APPLICATION CONCERNING MY
RESPONSIBILITIES. I declare under penalty of criminal laws of the state of North Dakota/Minnesota that this application has
been examined by me and to the best of my knowledge and belief is true, correct and complete.
Applicant’s Signature:
Date:
Email Address: (please print)
Telephone Number:
(include area code) (
) ________ - _____________
If you have additional comments, please use this space or attach paperwork if necessary.
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