THE NORTH CAROLINA COMMUNITY COLLEGE SYSTEM Appendix B Tab → to move to form fields APPLICATION FOR CLASSIFICATION AS A LEGAL RESIDENT (DOMICILIARY) OF NORTH CAROLINA FOR TUITION PURPOSES IMPORTANT NOTICE: Unless the Pitt Community College Admissions Office notifies you in writing of a change to in-state resident classification, your classification will remain non-resident for payment of enrollment tuition and fees. State law allows bona fide North Carolina legal residents (domiciliaries) to be eligible for a lower tuition rate than non-residents. North Carolina law (G.S. 116-143.1) requires you to establish legal residence (domicile) in North Carolina and maintain it for at least 12 months immediately prior to the beginning of the term for which you seek classification as a resident for tuition purposes. The statute also contains definitions, rules and special provisions for determining residence for tuition purposes. Copies of the law and the local institution’s policies may be obtained from each community college. If you are admitted to the college (or readmitted after a lapse in enrollment) the law requires the community college to classify you as a resident or non-resident for tuition purposes for your term of admission. If you claim North Carolina residence for tuition purposes, you must file this application before the end of the term for which you claim such residence. To be classified a resident for tuition purposes, you must give the college the evidence it requires to enable it to make that classification.

DIRECTIONS 1. PLEASE PRINT (in black ink) or TYPE ALL RESPONSES. If the question is not applicable to your situation, write “NA.” When “date” is requested, provide month, day and year. 2. PLEASE ANSWER ALL QUESTIONS accurately and completely. You are encouraged to write on the back of the application or attach additional sheets if you need more space to provide a complete answer. You are also encouraged to provide detailed, supplemental information concerning your residency claim. By providing complete answers initially, you help eliminate processing delays that occur when we must get in touch with you to obtain additional information. 3. IF YOU AND/OR YOUR SPOUSE ARE NOT U.S. CITIZENS, you need to fill out the “SUPPLEMENTAL FORM” that is attached to this application. 4. These forms must be returned to the Dean of Enrollment Management and Student Service, Pitt Community College, P.O. Drawer 7007, Greenville, NC 27835-7007 or you may FAX this document to (252) 321-4333. Please be sure that you have signed and dated this form before returning it. Documents you might submit in order to be considered for in-state tuition: □ □ □ □ □ □ □ □

N.C. Drivers License Employment History Filing of Income Taxes as a N.C. Resident Voter Registration Card N.C. Auto Insurance N.C. Auto Registration N.C. Mortgage/Lease Agreements Ownership of Real Property in N.C.

The Manual of Policies and Procedures of the state Residence Committee is on reserve in the Pitt Community College Library and available at the following website: http://www.northcarolina.edu/sites/default/files/documents/state_residence_classification_manual.pdf

NORTH CAROLINA RESIDENCE & TUITION STATUS APPLICATION APPLICANT INFORMATION

1.

Applicant Student’s Full Name:

2.

Social Security Number (voluntary):

Citizenship:

(If not a US citizen, attach completed Supplemental Form) - If Supplemental Form attached, check here:

3.

Date of birth:

/

4.

Address while attending institution (current):

5.

Permanent home address: Since:

6.

/

/

Place of birth:

/

Telephone:

Previous home address in NC: From:

/

/

To:

/

/

To:

/

/

Last previous home address outside NC: From:

/

/

7.

Are you currently enrolled in this yes Are you applying for admission? institution? no Check earliest term and indicate year in which you want this decision to apply: Year: Fall Spring Summer

8.

Why did you move your home to NC: On what date did you move your home to NC:

/

yes no

/

9.

From what state or foreign country did you move your home and legal residence:

10.

When do you claim your legal residence in NC began?

11.

Has your residence status for tuition purposes been previously determined by a North Carolina public educational institution? yes no If yes,

12.

(a)

Name of Institution:

(b)

Classification:

(c)

Last term and year you were so classified:

Resident

Address (place & state)

Nonresident

From (date)

To (date)

/

/

/

/

/

/

/

/

List ALL post-secondary schools (universities, colleges, junior colleges, community colleges, etc.) you have attended, in sequence (including this institution): Institution

14.

/

Secondary (high or preparatory) schools you attended in sequence: Name

13.

/

Father living?

Address (place & state)

yes

Permanent home address:

no

Name:

From (date)

To (date)

/

/

/

/

/

/

/

/

Occupation: Since:

/

/

15.

Mother living?

yes

no

Name:

Occupation:

Permanent home address: 16. 17.

18.

19.

Parents separated or divorced? Legal yes Guardian?

yes no

no

/

/

Who has/had custody of you?

Name:

Occupation:

Permanent home address:

Since:

/

/

Court appointed at (place)

(on date):

/

/

Who (including yourself) last claimed you as an exemption on state and/or federal income tax returns, for what tax year, and in what state filed? (a) On state return for tax year, filed in (state) on (date) / / Name: Relationship to you: (b) On federal return for tax year, filed in (state) on (date) / / Name: Relationship to you: (c) Does anyone intend to claim you as a dependent on state and/or federal income tax returns for the current tax year? yes no List in chronological order to date of this application all places you have spent at least 7 consecutive days during the past three years. Your response must include your current address, all other places lived, and vacations. Place (city & state)

20.

Since:

Occupation or Purpose

From (date)

To (date)

(a)

/

/

/

/

(b)

/

/

/

/

(c)

/

/

/

/

When and where (state or foreign country) did you do each of the following during the last 24 months? List each time you did each such act. If not done in the last 24 months, list where and when such acts were done the last time you did them; if never done at all, write “never”: (a)

Registered to vote:

(b)

Voted:

(c)

Called to serve on jury duty:

(d)

Acquired or renewed driver’s license: Acquired ownership of property for use as your principal dwelling: Inclusive dates of such property ownership:

(e) (f)

(g) (h) (i)

(j)

(k)

Where/Month/Day/Year

Where/Month/Day/Year

Where/Month/Day/Year

from:

/

/

from:

/

/

from:

/

/

to:

/

/

to:

/

/

to:

/

/

Filed state intangibles tax return: Listed personal property for taxation in the county where you live: Filed state income tax return: Did you file as a resident or nonresident?: Had state income tax withheld during the current tax year? yes no Beginning (month/day/year) / / During the previous year? yes no Beginning (month/day/year) / / Was all of the amount withheld refunded to you? yes no Registered/licensed a motor vehicle (car, truck, or other requiring license) – list all Type of vehicle: Type of vehicle: Where registered/licensed: Where registered/licensed: Month/Day/Year: / / Month/Day/Year

State(s): State(s):

/

/

21. The car(s) or other motor vehicles which you maintain and operate in NC are owned by: Name: Address: Registered/licensed in (state or foreign country): Insured in the name of: Address:

22. List the addresses at which you own and maintain personal property (clothing, furniture, cars, boats, checking or savings accounts, stocks, bonds, pets, jewelry, appliances, etc.) and give percentage of value (of total personal property) maintained at each address: Address

% at this address

(a) (b)

23. List your employment for wages in the last 24 months: Job Title

Address (place & state)

Employer

(a)

Date from: (month/year) /

Date to: (month/year) /

(b)

/

/

(c)

/

/

Hrs. per week

24. Of the total money required to meet your expenses, what percentage came from each of the following sources and what was it used for? Preceding Calendar Year (Jan.-Dec. Source

% of Total

Used For

)

Current Calendar Year (Jan.-Dec. % of Total

)

Used For

Your earnings Your savings Parent(s) or Guardian Name of Parent(s) or Guardian: Other (specify): Total

25. (a) (b)

100%

100%

Have you or either of your parents been in military service within the past two years? yes no If so, for each such person, ATTACH copies of the “Leave and Earnings Statements” for the most recent pay period 12 months ago. If you or either of your parents have been in active military service or other federal government employment within the past two years, answer the following for each such person:

Name(s): Relationship to you: Home address upon entry: Official “home of record”: Official home address now: Date this home address was declared:

/

/

/

/

Home address upon discharge: Date of discharge:

Legal residence most recently claimed on DD Form 2058 (State of Legal Residence Certificate): Place to which mileage was paid Date that DD Form 2058 was completed: / / upon discharge: State for which income tax withheld: From what date:

/

/

26. Answer the questions below for each of the following individuals:  Your parents (or legal guardian) if you now live with them or have lived with them in the past 24 months OR if they have claimed you as a dependent for tax purposes in the past 24 months. Answer this question for your father unless your parents are separated or divorced. If your parents are separated or divorced, answer this question for both parents.  Any other person who has claimed you as a dependent for tax purposes within the past 24 months. (a)

Name(s):

Relationship to you:

Permanent home address: Lived at this address since (date):

/

/

Last previous home address:

(b)

From (date): / / To (date): / / Where (state or foreign country) and when did this person do each of the following during the last 24 months? List each time he or she did each such act. (If not done in the last 24 months, where and when did he or she do these acts last? If never done at all, write “never”): Where/Month/Day/Year Where/Month/Day/Year Where/Month/Day/Year

1.

Registered to vote:

2.

Voted:

3.

Called to serve on jury duty:

4.

Acquired or renewed driver’s license: Acquired ownership of property for use as your principal dwelling: Inclusive dates of such property ownership:

5. 6.

7.

Filed state intangibles tax return :

8. 9.

Listed personal property for taxation: Filed state income tax return:

10. 11.

Did you file as a resident or nonresident?: Registered/licensed motor vehicle(s): Claimed you as an exemption on state income tax return for: Claimed you as an exemption on federal income tax return for:

from:

/

/

from:

/

/

from:

/

/

to:

/

/

to:

/

/

to:

/

/

Tax Year:

File in (state):

Tax Year:

File in (state):

On (date): / / On (date): / /

27. If there are additional circumstances, events, or acts that you feel support your claim to North Carolina legal residence (domicile) for tuition purposes, attach a description of each, specifying the place and date of its occurrence.

PART IV (SUPPLEMENTAL FORM) 1.

If you are an alien, answer and complete the following appropriately: (a)

I possess a valid, current visa: yes no My visa has the designation of: (A, B, C, D, E, F, G, H, I, J, K, L, or M plus a number). Note: B, C, D, F, H, J, and M visas reflect a presence in the United States not sufficient to support a bona fide claim to North Carolina legal residence. My visa was issued as of (date): / /

(b)

I possess a valid, current Form I-151 or I-551 (Alien Registration Receipt Card): Its Registration Number is: It reflects my entry into the United States as an immigrant on (date): /

yes

no

/

(c)

I possess a valid, current Form I-181b (Memorandum of Creation of Record of Lawful Permanent Residence): yes no It reflects my entry into the United States as an immigrant on (date): / /

(d)

Immediately before I received my form I-151 (or Form I-551 or Form I-181b), I possessed a valid current visa: yes no This was an immigrant visa: yes no This was a visa with letter designation of: My visa was issued as of (date): / /

(e)

I possess a valid, current Form I-94 (Arrival-Departure Record) Parole Edition: The parole date on the form is (date): / /

(f)

I possess a document issued by immigration authorities (letter, form, certificate, etc.) that shows that I will later be issued one or more of the documents described above: yes no Its effective date is: / / Identify: (Attach a copy if permitted by immigration law. If not, be prepared to display the document for inspection upon request.)

(g)

I possess a document issued by immigration authorities not identified above that supports my claim to resident tuition status: yes no Its effective date is: / / Identify: (Attach a copy if permitted by immigration law. If not, be prepared to display the document for inspection upon request.)

Applicant’s Signature:

Date:

yes

no

/

/



I hereby acknowledge that completion of Item 2 (Social Security number) is voluntary, is requested by the institution solely for administrative convenience and record-keeping accuracy, and is requested only to provide a personal identifier for the internal records of this institution.



I hereby certify that all information I have set forth herein is true to the best of my knowledge, pursuant to my reasonable inquiry where needed.



I hereby acknowledge that the institution may verify the information set forth herein from sources accessible under law to the institution but that the institution may divulge the contents of this application only as permitted under the Family Educational Rights and Privacy Act of 1974 if I am, or have been, in attendance at this institution.

Applicant’s Signature:

Date:

/

/

Date:

/

/

If applicant is under 18 years of age: Parent/Guardian Signature:

8/31/09