Supplemental Residency Questionnaire Template printable pdf download

LOS ANGELES COMMUNITY COLLEGE DISTRICT

SUPPLEMENTAL RESIDENCY QUESTIONNAIRE

New ____ Continuing _____

Semester Reclassification requested for:

Winter [ ]

Spring [ ]

Summer [ ]

Fall [ ]

20_____

PART A – TO BE COMPLETED BY ALL STUDENTS

Print Full Name – Last

First

Middle

Age

Social Security # (or College ID#)

Birthdate

Birthplace

Are you a citizen of the United States?

When did your present stay in California begin?

[ ] Yes

[ ] No

(Mo/Day/Yr)

Permanent Legal Address (Number, Street, City, State, Zip)

Home Phone:

Work Phone:

Cell Phone:

E-mail:

Have you lived in California continuously since birth? [ ] Yes [ ] No If “no” , list places you lived before your present stay in California began, with dates:

(a)

From _____________ to _____________ State/Country: ______________ (b)

From ____________ to _____________ State/Country: _____________

(c)

From _____________ to _____________ State/Country: ______________ (d)

From ____________ to _____________ State/Country: _____________

If you (1) attended a high school in California for three or more years, (2) graduated from a high school in California or attained the

equivalent (e.g., GED or Certificate of Proficiency), and (3) are not an nonimmigrant alien as defined by federal law (e.g., J or F visa),

please request an AB 540 California Nonresident Tuition Exemption Request form. If you are currently without lawful immigrant status,

you may still qualify for the exemption if you have filed or will file an application to legalize your status.

PART B – TO BE COMPLETED BY STUDENTS UNDER 19 YEARS OF AGE

1. (a) Mother’s name: _________________________________

(b) Is your mother living? [ ] YES [ ] NO Date deceased: __________________

If answer to (b) was “yes,” answer the following:

(d) If in California, for how long? _______________________

(e) Is your mother a U.S. citizen? [ ] YES [ ] NO

If “no,” what is her immigration status? _________________________________________________

2. (a) Father’s name: __________________________________

(b)

Is your father living? [ ] YES [ ] NO Date deceased: __________________

If answer to (b) was “yes,” answer the following:

(d) If in California, for how long? ___________

(e) Is your father a U.S. citizen? [ ] YES [ ] NO

If “no,” what is his immigration status? _________________________________________________

3. (a) Where do you live?

[ ] with mother

[ ] with father

[ ] somewhere else

(b) If you do not live with either parent, are you under continuous and direct care and control of any person or persons other than a parent? [ ] YES [ ] NO

If “yes,” give name and address of such person: _________________________________________________________________________________________

How long have you been continuously under this person’s direct care and control? ______________________________________________________________

Please bring at least two items documenting your parent’s or guardian’s California residency. The documentation items must be

valid, readable, and cover the one year and one day period before the first day of the semester. See Part F for a list of acceptable

documents. Examples include the following: state income tax returns from the previous year; evidence of ownership or occupation

of residential real estate in California; utility bills and bank statements with a California address covering the one year and a day

period before the first day of the semester.

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Supplemental Residency Questionnaire Template

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