Richard Bland College In State Tuition Application (Page 2 of 2) in pdf

ONLY COMPLETE THIS FORM

IF SOMEONE PROVIDES MORE THAN 50% OF YOUR FINANCIAL SUPPORT

Richard Bland College Supplemental In-State Residency Form: SIDE B

MUST BE COMPLETED IN INK

by the

Legal Guardian/Spouse

Applicant’s Legal Name: _________________________________________________ Applicant’s Social Security Number: _________________________________

Name of , legal guardian/spouse: ___________________________________________________________________________________________________________

Relationship to applicant: _________________________________________________________________________________________________________________

How long have you lived in Virginia? ________________________________________________________________________________________________________

Are you a citizen of the United States? ________ If you are a non United States citizen, please indicate you type of VISA: ____________________________________

What is your present city or county of residence? _______________________________________________________________________________________________

Where have you lived for the past two years? List all addresses beginning with the most recent.

From

Street Address

City

State

Zip Code

(mm/yy)

___/____

_______________________________________

_________________________________________

_____________

____________

___/____

_______________________________________

_________________________________________

_____________

____________

Do any of the following characteristics apply to you? (Please place an X in appropriate boxes.)

□ Yes □ No

I have claimed the applicant as a dependent on my federal & Virginia income taxes for the tax year prior to the term in which the applicant will enroll.

□ Yes □ No

I have provided more than 50 percent of the applicant’s financial support for at least one year prior to the term in which the applicant will enroll.

□ Yes □ No

For at least one year prior to the term in which the applicant will enroll at Richard Bland College, I have been employed.

□ Yes □ No

For at least one year prior to the term in which the

□ Yes □ No

I filed taxes to another state: _________________________________

applicant will enroll at Richard Bland College, I have

filed a tax return or paid income taxes to Virginia on

□ Yes □ No

I am disabled. (Document indicating income from disability is required

all earned income.

to be submitted along with this application before it can be processed.)

□ Yes □ No

I am/was on public assistance. (Document indicating income from

□ Yes □ No

I have a valid Virginia driver’s license

public assistance is required to be submitted along with this application

Before it can be processed.)

□ Yes □ No

For at least one year prior to the term the applicant

□ Yes □ No

Other (Please explain):_____________________________________

will enroll at Richard Bland College, I have owned or

operated a motor vehicle in Virginia.

_______________________________________________________

Military Service:

(If you answer YES to any question below, the following documents are required and must be submitted to the Registrar’s Office

along with this application before it can be processed.) Copies of (1.) Leave & Earnings Statement; (2.) Orders; and (3.) Student (dependent’s) military

ID front & back.

□ Yes □ No

I am a member of the United States Armed Forces at the present time.

□ Yes □ No

My legal guardian/spouse is presently a member of the United States Armed Forces.

□ Yes □ No

I have attached a copy of the most recent Leave and Earnings Statement from the person who is a member of the US Armed Services.

□ Yes □ No

Virginia income taxes have been paid on all military income for one year prior to the term in which I will be enrolled.

□ Yes □ No

My legal guardian/spouse is in the military. I have resided in Virginia, been employed, earned income that equates to 50 weeks 40 hours each week

multiplied by the current minimum wage and paid income taxes to Virginia for at least one year prior to the term in which I will be enrolled.

□ Yes □ No

I/ my legal guardian/spouse have/has changed his/her state of legal residence to Virginia effective on this date _________________.

I have attached a copy of the military orders or other military-acknowledged documentation, which verifies this change.

Answer this question only if you live outside Virginia but work in Virginia:

□ Yes □ No

I have lived outside Virginia, worked in Virginia, earned income that equates to 50 weeks X 40 hours each week X current minimum wage, and

paid Virginia income taxes on all taxable income earned in the Commonwealth for at least one year prior to the term in which I will enroll.

I certify that the above statements are true and correct to the best of my knowledge.

_______________________________________________________________________________________

_____________________________________________

Signature of legal guardian/ spouse

Date

(This form is not complete without a signature.)

THE LEGAL GUARDIAN/SPOUSE WHO PROVIDES MORE THAN 50% OF

FINANCIAL SUPPORT FOR THE APPLICANT MUST SIGN THIS DOCUMENT.

Richard Bland College In State Tuition Application Page 2

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