Residency Reclassification Request Form Page 3

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Residency Reclassification Request Form
Student Name:__________________________________________________________ DOB:________/________/_________ Connections User ID____________________________
Last
First
(If yes, skip to claimant documentation)
Are you the person claiming Florida residency?
Yes
No
PERSON CLAIMING FLORIDA RESIDENCY
Relationship to Student:
Parent
Legal Guardian
Spouse
Other______________ (
Documentation required)
(Court documentation required)
(Marriage certificate or military ID required)
Claimant’s Name___________________________________________________________________________________________________Claimant Birth Year___________________
Last
First
Middle
Claimant is a U.S. Citizen?
Yes
No (
)
complete Immigration Info
Non U.S Citizens: Legible copy of current immigration document required-resident alien card, Visa and I-94 card, etc.
Immigration: Alien Resident?
Yes
No
Alien Number ________________________ Visa Type _________ Expiration Date________________ Other__________________
Claimant’s Address________________________________________
_________________________________
________________
________________
_________________
Number/Apt.# or P.O. Box and Street
City
State
ZIP Code
County
Date Claimant Established Legal Residence in Florida _________\________\_________Telephone (________)________________________ (________)_______________________
Home or Cell
Work
CLAIMANT DOCUMENTATION
Documents supporting the establishment of legal residence must be dated, issued or filed 12 months before the first day of classes for which a Florida resident classification is
sought. Please review the required proof (see table above) linked to your residency claim.
All documentation is subject to verification. Additional documents such as tax
returns, birth certificates, court documents, etc. may be requested.
Yes (provide a mortgage, deed or home stead exemption)
1.
Do you currently own a home in Florida?
Purchased Date
_________\________\_________
No
2.
Are you employed 30 hours or more in
Florida?
Yes (submit employment proof)
Hire Date
_________\________\_________
No
Yes (Proof required)
3.
Do you have a Florida Driver License or
_____________________________________
_________\________\_________
State ID?
No
License Number
Issue Date
_____________________________________
Yes (Proof required)
4.
Are you registered to vote in the state of
_________\________\_________
Voter Registration Number
Florida?
Issue Date
No
____________________________________
Florida County
______________________________________
Title Number or
Yes (Proof required)
5.
Do you have vehicle registered in the
_________\________\_________
state of Florida?
Issue Date
No
____________________________________
VIN Number
PROVIDE ADDITIONAL INFORMATION BELOW IF ALL OF THE FOLLOWING APPLY:
THE CLAIMANT DID NOT ANSWER “YES” TO AT LEAST 4 QUESTIONS IN THE REQUIRED INFORMATION SECTION.
1.
THE 4 DOCUMENTS DO NOT MEET THE 12-MONTH REQUIREMENT.
2.
THE CLAIMANT/STUDENT IS NOT ELIGIBLE FOR A RESIDENCY
EXCEPTION OR
QUALIFICATION.
3.
List additional documents you would like to submit to support your request for reclassification. Submit copies to support each document.
ISSUED BY IN THE STATE OF FLORIDA
Type of Document: _______________________________________________
Yes (Proof required)
_________\________\_________
_______________________________________________________________
No
Issue Date
ISSUED BY IN THE STATE OF FLORIDA
Type of Document: _______________________________________________
Yes (Proof required)
_________\________\_________
_______________________________________________________________
No
Issue Date
ISSUED BY IN THE STATE OF FLORIDA
Type of Document: _______________________________________________
Yes (Proof required)
_________\________\_________
_______________________________________________________________
No
Issue Date
I do hereby swear or affirm that the above named student meets all requirements indicated in the checked category above for classification as a Florida resident for tuition purposes. I understand that a false
statement in this affidavit will subject me to penalties for making a false statement pursuant to 837.06, Florida Statutes.
Claimant’s Legal Signature ________________________________________________________________________________________
Date____________________________
Student’s Signature (If other than claimant) _________________________________________________________________________
Date____________________________
Admissions Revised 9/12
Page 3 of 3
Print and Sign. Return this form to your campus Student Success Center or fax to the Welcome Center (904) 633-5955.

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