Application for Virginia In-State Tuition Rates

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Submit this form if you are claiming entitlement to Virginia in-state tuition rates pursuant to section 23-74, Code of Virginia. All questions must be answered. Failure to complete this form will result in a classification of non-Virginia domicile. Please return this form, along with a photocopy of your Virginia driver's license, to VTOnline Registration, University Gateway Center, Suite 120, 902 Prices Fork Rd. Mail Code: (0392), Blacksburg, VA 24061, or fax to: 540-231-2079.

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SECTION A: APPLICANT INFORMATION

Name _____________________________________ U.S. Social Security number: _____-____-________

(Check one): U.S. Citizen  Permanent Resident  non-Permanent Resident/Visa Type _________

How long have you lived in Virginia ? Years ______ Months ______

Where have you lived in the last two years? Please list current address first:

Street Address                              City                              State                              Zip                              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, sign Section D and have your parent/legal guardian/spouse complete section B. Section C does not have to be completed.
If no, you must complete Sections C and D.

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SECTION B: PARENT, SPOUSE, OR LEGAL GUARDIAN INFORMATION

Name _____________________________________ U.S. Social Security number: _____-____-________

Relationship to Applicant (check one):  mother  father  legal guardian  spouse

Date of Birth (mo/day/year): ____________________ Home Phone: (___) _____________________

Personal Email address: _____________________________________________________________

Citizenship (check one): U.S. Citizen  Permanent Resident  non-Permanent Resident/Visa Type _________

How long have you lived in Virginia ? Years ______ Months ______

Where have you lived in the last two years? Please list current address first:

Street Address                              City                              State                              Zip                              From (mo/yr) To (mo/yr)

_________________________________________________________________________________________________

_________________________________________________________________________________________________

_________________________________________________________________________________________________

For the twelve months prior to the term in which the applicant will enroll, will you have:

• filed a tax return or paid income taxes to Virginia?  yes  no

• been a registered voter in Virginia?  yes  no

• held a valid Virginia driver's license?  yes  no

• owned or operated a vehicle?  yes  no
  4a. If yes, has it been registered in Virginia?  yes  no

• Answer this question only if you worked in Virginia but lived outside Virginia for the past 12 months: Did you file Virginia taxes on all taxable income earned in Virginia for the last tax year?  yes  no

• Are you currently on active duty in the military? (If no, please skip to Section D.)  yes  no
  a. Are you currently stationed in Virginia?  yes  no
  b. Does your Leave and Earnings Statement reflect Virginia as your state of residence?  yes  no

• If you are active duty military, did your spouse earn at least $10,300 in the last year, claim the applicant as a federal tax dependent, and pay income tax to the state of Virginia?  yes  no
  If yes, please include a copy of the first page of your federal and state tax form.

_ Please remember to sign Section D. _

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SECTION C: STUDENT INFORMATION

For the twelve months prior to the term in which you will enroll, will you have:

• filed a tax return or paid income taxes to Virginia?  yes  no

• been a registered voter in Virginia?  yes  no

• held a valid Virginia driver's license?  yes  no

• owned or operated a vehicle?  yes  no
  4a. If yes, has it been registered in Virginia?  yes  no

• Will you be age 24 before the first day of classes?  yes  no

• Are you a veteran of the U.S. Armed Forces or active duty military?  yes  no

• Are you married?  yes  no

• Are you a ward of the court or were you a ward of the court until age 18?  yes  no

• Do you have legal dependents (other than a spouse)?  yes  no

• Answer this question only if you worked in Virginia but lived outside Virginia for the past 12 months: Did you file Virginia taxes on all taxable income earned in Virginia for the last tax year?  yes  no

• If you currently on active duty in the military:
  a. Are you currently stationed in Virginia?  yes  no
  b. Does your Leave and Earnings Statement reflect Virginia as your state of residence?  yes  no

_ Please remember to sign Section D. _

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SECTION D: CERTIFICATION

The applicant must sign below or this application will not be processed.

If Section B has been completed by a parent, spouse or legal guardian that person's signature must also appear below.

I certify under penalty of disciplinary action that the information I have provided is true.

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Signature of applicant                                                                                        Date

I certify that the information I have provided is true.

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Signature of Parent, Spouse or Legal Guardian                                                        Date