UNCG
North Carolina Residency Questionnaire (Short Form)
The following information is required for all NC Residents.
•Return to:
UNCG - Undergraduate Admissions PO Box 26170
Greensboro, NC 27402
•E-mail to admissions@uncg.edu or
•Upload it in Spartanlink
NOTE: Failure to complete this form in full will delay notification of an admission decision and will result in a non-resident classification for tuition purposes (you will be charged the out-of-state tuition rate). If you have any
questions about your residency, please contact Undergraduate Admissions at (336) 334-5243.
Instructions:
Answer all questions completely. Print clearly in ink or type. Do not leave any spaces blank. If questions do not apply to you, please write “N/A” – omitted information may result in a non-resident classification for tuition purposes. Please submit this form to Undergraduate Admissions in one of the three ways described above. Faxed copies are not accepted.
Full Legal Name ___________________________________________________________________________________________________________
1.Date of Birth ______/______/______ Place of Birth _________________________________ Citizenship ____________________ Sex ______
2.Permanent Address (Street) ______________________________________________________________________________________________
(City, State, Zip) ____________________________________________________________________________________ Since ___/_____/_____
3.Current Mailing Address (Street) _________________________________________________________________________________________
(City, State, Zip )__________________________________________________________________________________ Since _____/_____/_____
|
mo. day |
yr. |
4. Current Telephone (______)_______________________ |
E-mail ____________________________________________________________ |
5.Previous Address (Street) ________________________________________________________________________________________________
(City, State, Zip )_________________________________________________________________ From ____/____/____ Until ____/____/____
6.Last Address Outside NC (Street) _________________________________________________________________________________________
(City, State, Zip )__________________________________________________________________ From ____/____/____ Until ____/____/____
mo. day yr. mo. day yr.
8. Do you claim to be a legal resident of North Carolina for the last 12 months for tuition purposes? |
Yes |
No |
If “yes,” please complete the rest of the information below.
9.Driver’s license acquired: When______________(month/year) Where______________(state)
Driver’s license renewed: When______________(month/year) Where______________(state)
10. Have you been in active military service or have you been a military dependent in the past 12 months? Yes No
If “yes, ” attach to this application copies of the “Leave and Earnings Statement” for the most recent pay period and for the pay period 12 months ago for each such person.
11. Have you ever worked outside of North Carolina? |
Yes |
No |
NAME _____________________________________________________________________________________________ |
PAGE 2 |
12. Please list ALL of your employment for wages in the past 24 months (include a separate sheet if needed):
Job Title EmployerAddress (City, State)From (mo./yr.) To (mo./yr.) Hrs/Week
__________________________________________________________________ ________/___________/____________/___________
__________________________________________________________________________/____________/____________/___________
__________________________________________________________________________/____________/____________/___________
__________________________________________________________________________/____________/____________/___________
Parent / Guardian Information: |
|
13. Is your father living? Yes No |
Father’s Name _____________________________________________________ |
Current Address (Street) ________________________________________________________________________________________________
(City, State, Zip) _________________________________________________________________________________ Since _____/_____/_____
Previous Address (Street) _______________________________________________________________________________________________
(City, State, Zip )________________________________________________________________ From ____/____/____ Until ____/____/____
mo. day yr. |
mo. day yr. |
State of Legal Residence ______________________________________________________________ Since (mo./ day/ yr.) |
____/____/____ |
Employer ___________________________________________________________________________________________________________
Occupation ___________________________________________ Location (City, State) __________________________________________
Highest Education Level Completed (or degree received) ________________________________________________________
Is your father a UNCG graduate? Yes No
14. Is your mother living? Yes No Mother’s Name ___________________________________________________
Current Address (Street) _______________________________________________________________________________________________
(City, State, Zip) ________________________________________________________________________________ Since _____/_____/_____
Previous Address (Street) ______________________________________________________________________________________________
(City, State, Zip )_______________________________________________________________ From ____/____/____ Until ____/____/____
mo. day yr. mo. day yr.
State of Legal Residence ______________________________________________________________ Since (mo./ day/ yr.) ____/____/____
Employer __________________________________________________________________________________________________________
Occupation __________________________________________ Location (City, State) _________________________________________
Highest Education Level Completed (or degree received) ________________________________________________________
Is your mother a UNCG graduate? Yes No
NAME ____________________________________________________________________________________________ PAGE 3
15. Are your parents separated or divorced? Yes No If yes, who has legal custody? _______________________________
16.Guardian Name (if not living with parents) _________________________________________________________________________
Current Address (Street) _______________________________________________________________________________________________
(City, State, Zip) ________________________________________________________________________________ Since _____/_____/_____
Previous Address (Street) ______________________________________________________________________________________________
(City, State, Zip )_______________________________________________________________ From ____/____/____ Until ____/____/____
mo. day yr. |
mo. day yr. |
State of Legal Residence ______________________________________________________________ Since (mo./ day/ yr) |
____/____/____ |
Employer ___________________________________________________________________________________________________________
Occupation ___________________________________________ Location (City, State) __________________________________________
Highest Education Level Completed (or degree received) ________________________________________________________
Tax Information:
17.A: Did you claim yourself as an exemption on income tax returns last year?
(if you filed your own taxes and no one else claimed you, check “yes”) Yes No
If “yes,” in what state did you file? ____________________________________________________________________
B:If someone else claimed you on his/her income taxes, please provide the following information: Who last claimed you as a dependent or exemption on income tax returns?
Name _______________________________________________________________________________________________
Relationship ______________________________ Tax Year _____________ State filed _______________________
C:Do you intend to claim yourself as an exemption on income tax returns for the current year?
(if you intend to file your own taxes and no one else will claim you, check “yes”) Yes No
If “yes,” in what state do you intend to file? _____________________________________________________________
D:If someone else intends to claim you as a dependent or exemption on income tax returns for the current year, please provide the following information:
Name _______________________________________________________________________________________________
Relationship _____________________________ Tax Year ____________ State to be filed ___________________
NAME ______________________________________________________________________________________________ PAGE 4
18. Student Residency Agreement:
_____ I have answered all questions. If any questions were not applicable to my situation, I have written “N/A”. Whenever dates are
Initials requested, I have given month/day/year as accurately as possible. I understand that failure to answer all questions may result in being classified as an out-of-state resident for tuition purposes.
_____ I certify that the responses provided are true and complete to the best of my knowledge. I understand my failure to provide
Initials complete, accurate, and truthful information will be grounds to deny or withdraw my admission or dismiss me after enrollment.
_____ I understand that submission of this form does not guarantee a classification of in-state residency and that I might be asked for
Initials additional information in support of my claim to the in-state tuition benefit.
_____ I also agree to inform the Office of Undergraduate Admissions, in writing, of any change of address or residency.
Initials
_____ I understand that if I do not attend UNCG, discontinue my enrollment at UNCG at any time, or do not complete my admissions
Initials application, I will be required to re-apply and re-submit my residency information.
___________________________________________________________________ |
______/______/______ |
Signature of Applicant |
Date (month/day/year |
Additional Information:
(Please use this space or attach a separate sheet for any additional information or explanation pertaining to your residency.)
