| A. Applicant Information: |
| *Legal Name: *SS Number: -- |
| *Home Phone: - - *Work Phone: - - | Cell Phone: - - |
| *Mailing Address: * E-mail: |
| *City: *State: *Zipcode: |
| *Are you a U.S. citizen? Yes No Non-permanent Resident / Visa Type: |
| *How long have you resided in Virginia? Years Months |
| *Where have you lived in the last two years? Please list current address first. |
| Street: | City: | State: | Zipcode: | From (mo/yr) | To (mo/yr) |
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| *Do your parents/legal guardian/spouse provide 50% or more of your financial support or claim you as a tax dependent? Yes No |
If YES, complete Sections B, C and D and request your parent/legal guardian/spouse to complete Section B. Section C does not have to be completed.
If NO, you must complete Sections C and D. |
| *I am applying as a: First-time freshman Transfer student Non-degree seeking student Re-admit student |
| B. Parent, Spouse, or Legal Guardian Information (back to top) |
| Name: | |
| SS Number: - - Relationship to Applicant: Mother Father Legal Guardian Spouse |
| Date of Birth: | Home Phone: - - |
| Work or Cell Phone: - - | E-mail: |
| Mailing Address: |
| City: State: Zipcode: |
| Are you a U.S. citizen? Yes No Non-permanent Resident / Visa Type: |
| How long have you resided in Virginia? Years Months |
| Where have you lived in the last two years? Please list current address first. |
| Street: | City: | State: | Zipcode: | From (mo/yr) | To (mo/yr) |
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| For the 12 months prior to the term in which the applicant will enroll, will you have: |
| 1. Filed a tax return or paid income taxes to Virginia? Yes No |
| 2. Been a registered voter in Virginia? Yes No |
| 3. Held a valid Virginia driver’s license? Yes No |
| 4. Owned or operated a motor vehicle? Yes No If YES, is it or has it been registered in Virginia? Yes No |
| 5. Did you file Virginia taxes on all taxable income earned in Virginia for the last tax year? Yes No |
6. a. Are you currently on active duty in the military? If NO, please skip to Section D. Yes No
b. Are you currently stationed in Virginia? Yes No
If YES, you must provide the university with copies of the following: official military orders assigning you to a permanent duty
station in Virginia, official documentation of your residence in Virginia (deed, lease, or letter from landlord), and a copy of the
student’s military identification card (if unavailable, a copy of your federal tax returns indicating dependency)
c. Does your Leave and Earnings Statement (LES) reflect Virginia as your current state of residence? Yes No |
7. If you are active duty military, did your spouse earn at least $10,500 in the last year, claim the applicant as a federal tax dependent, and
pay income to the Commonwealth of Virginia? Yes No
If YES, please include a copy of the first page of your federal and state tax forms. |
| C. Student Information (back to top) |
| 1. Filed a tax return or paid income taxes to Virginia? Yes No |
| 2. Been a registered voter in Virginia? Yes No |
| 3. Held a valid Virginia driver’s license? Yes No |
| 4. Owned or operated a motor vehicle? Yes No If YES, is it or has it been registered in Virginia? Yes No |
| 5. Will you be age 24 before the first day of classes? Yes No |
| 6. Are you a veteran of the U.S. Armed Forces or active duty military? Yes No |
| 7. Are you married? Yes No |
| 8. Are you a ward of the court or were you a ward of the court until age 18? Yes No |
| 9. Do you have legal dependents other than a spouse? Yes No |
| Note: Answer the following questions ONLY if you worked in Virginia but currently live outside of Virginia. |
| 10. Did you file Virginia taxes on all taxable income earned in Virginia for the last tax year? Yes No |
11. a. If you are currently on active duty in the military, are you currently stationed in Virginia or have you been ordered to a
permanent duty station in Virginia? Yes No
b. Does your Leave and Earnings Statement (LES) reflect Virginia as your state of legal residence? Yes No
If YES, include a copy of your most recent LES. |
| D. Signature(s) (back to top) |
| I certify that all of the information provided in this application is true and accurate. I understand that this application is a legally-binding document and that if I provide fraudulent information, I may be subject to repayment or dismissal. I agree to furnish the University with supporting documentation related to my application, if I am requested to do so.
Applicant's Full Name: (in lieu of signature)
Parent/Spouse/Guardian: (in lieu of signature)
I certify under penalty of disciplinary action that the information I have provided is true. |
