Supplemental Residency Questionnaire Template (Page 4 of 4) in pdf

PART F – TO BE COMPLETED BY ALL STUDENTS

The burden of proof is on the student to clearly demonstrate both physical presence in California and intent to establish a

permanent home in California. You are required to present evidence in accordance with Education Code Sections 68040 et seq.

You must bring two of the following kinds of documents from the list below. The documents presented must be valid, readable

and cover the one year and one day period before the first day of the semester. Documents should also be properly identified

with respect to student name and a corresponding California address.

Call __________________________________ to make an appointment. When you come in, bring this form, your original

documentation and a copy of the documentation. Do not mail or fax this form.

****NEED TWO FROM THE FOLLOWING LIST****

PLEASE CHECK ITEM (S) SUBMITTED

[ ] California state income tax forms from previous year

[ ] California driver’s license and/or California identification card

[ ] Documentation of purchase and/or lease of

[ ] Active California checking or savings account for

residential real estate in California covering a one year period

one year period

[ ] California automobile registration

[ ] Selective Service registration with California permanent address

[ ] California voter registration

[ ] Receipt of benefits from a California state agency covering a

[ ] Credit card statements with a California address

one year period

covering a one year period

[ ] California high school transcripts

[ ] Utility bills (gas, water, power, telephone) with a California [ ] Any California occupational license

address covering a one year period

[ ] Miscellaneous (Please list: _________________________________ )

DECLARATION – TO BE COMPLETED BY ALL STUDENTS

I certify under penalty of perjury that all the information I have given on this form is true and complete to the best of my

knowledge. I understand that falsification or withholding of information requested shall constitute grounds for dismissal. I

understand that I will be requested to provide proof of some statements in accordance with Education Code Sections 68040 et seq.

______________________________________________________

__________________________

Student’s Signature

Date

FOR OFFICE USE ONLY

Residence Code: _______________

Classified By: _________________ Date: __________________

Pending:

Interviewed By: ___________________

Date: ________________

Documents requested:

________________________________________________________________________

_______________________________________________________________________________

Page 4 of 4

Supplemental Residency Questionnaire Template Page 4

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