University of California at Santa Cruz

PETITION FOR CHANGE OF LEGAL RESIDENCE STATUS

For term beginning: Fall 20_____ Undergraduate Winter 20_____ Spring 20_____ Graduate

Resident

FOR DEPUTY'S USE ONLY Nonresident

By ________________________ Date _______________________

Notes:

Please complete in ink, sign, and date.

The Campus Residence Deputy will review your petition by appointment only. Call 831-459-4412 to schedule an appointment. Please petition before the beginning of the relevant quarter.

Print full name:

Last

First

Middle

Student ID No.

Birthdate

Age

Present mailing address: Number, Street, City, State, Zip

Telephone No.

Permanent residence: Number, Street, City, State, Zip

e-mail

Do you claim to be a resident of California? Are you a citizen of the United States? If no, have you been awarded permanent residence? If no, have you applied for permanent residence status? If yes, do you currently hold a valid immigration visa status?

Yes Yes Yes Yes Yes

No No No No No

Motor Vehicle:
Do you have a drivers license? Yes No If yes, in which state_________________________ Date issued________________________________ Last renewed ______________________________ If a non-driver, do you have a state identification card? Yes No If yes, in which state _______________________ Date issued ______________________________ Do you have a motor vehicle? Yes No If yes, date of registration ____________________ State of registration _________________________

Alien registration number ______________________ Date awarded _____________________ Visa type ___________________________ valid from ________________ to ______________
Non-citizens, please attach proof of your INS status

Dates of Physical Presence in California:

Continuously since birth

From _______________ To ______________ From _______________ To _______________ If you claim California residence but have been absent from the state for more than six weeks during the last 12 months, please attach a statement explaining your absence. Were you enrolled at a U.C. campus prior to fall 1993? Are you a veteran of the U.S. armed forces? Are you a ward of the court? Do you have legal dependents other than a spouse? Yes Yes Yes Yes No No No No
2 Calendar Years Ago

Voter Registration:
Are you registered to vote? Yes No State of registration _______________________ Date of registration _______________________ Have you voted within the last 15 months? Yes No If yes, in which state __________ date_________

Financial Information:
What is your source of financial support? Will your/did your parents claim you as an exemption on their tax returns? Will you/did you file a California resident income tax return? Will you/did you file a resident income tax return in another state? If yes, what state _________________________ Are you/were you employed in California? outside California? Will you/did you receive loans, scholarships, or benefits that required residence outside California? If yes, attach a statement describing.

This Calendar Year

Last Calendar Year

__________ Yes No Yes No Yes No Yes No Yes No Yes No

__________ Yes No Yes No Yes No Yes No Yes No Yes No

__________ Yes No Yes No Yes No Yes No Yes No Yes No

Bank Accounts:
Checking: _________
State

_____________________
Date established Date established

Savings:

_________ _____________________
State

Marital Status:
Single Married: Date ___________ State _________ Divorced: Date ___________ State _________ Do you hold any professional licenses? Yes No If yes, valid from ___________to _____________ in state of ________________________________ What state do you regard as your permanent home? _________________________________ How long has it been your home? ______________ Do you plan to remain in California after completing your education? Yes No

Colleges or Universities Attended:

From To Name of School State ______________ ______________ ___________________________________ ________ ______________ ______________ ___________________________________ ________ ______________ ______________ ___________________________________ ________
If you claim to be a resident of California and are/were attending a public or private school outside California within the last two years, please have the school send a letter stating your residence status for tuition purposes and your permanent address on their records.

U.S. Military Service:

Are you or your spouse currently on active duty? If yes, state of legal residence Are you registered with the selective service? If yes, state of registration

Student Yes No _____________ Yes No _____________

Spouse Yes No ______________

Signature required on reverse

If you are under 24 years of age, complete the remainder of this form. If not, please sign and date below.
If a parent is deceased, give date and place of death; otherwise provide all information required. Father: ______________________________________________________ Mother: _____________________________________________________
Date Place Date Place

Are your parents currently on active duty in the United States military? Stationed in California: Stationed outside California: State of legal residence: Are your parents divorced or permanently separated? Yes No If yes, who have you been living with? Mother Father Other ___________________________________

Father Yes No from ___________ to ____________ from ___________ to ____________ ______________________________

Mother Yes No from ___________ to ___________ from ___________ to ___________ _____________________________

Have you resided with your other parent since divorce or separation? Yes No If yes, from ______________________ to __________________________ (state name and relationship) Address _____________________________________________________ Dates of residence with person noted above: From _______ to _______ address __________________________________ From ___________________________ to __________________________ From _______ to _______ address _________________________________ Address _____________________________________________________

Does he claim to be a California resident? Yes No Students Father: ___________________________________________________________________________ Is he a U.S. citizen? Yes No Fathers full name: Last First Middle Is he a U.S. permanent resident (PR)? Yes No ___________________________________________________________________________ If no, has he applied for PR status? Yes No Address: Number, Street, City, State, Zip If yes, does he currently hold a valid Dates of Fathers Physical Presence in California: Continuously since birth immigration visa status? Yes No From ______________ To ______________ From ______________ To ______________ If he claims California residence but has been absent from the state for more than six Alien registration # _______________________________ weeks during the last 12 months, please attach a statement explaining his absence. Date awarded ___________________________________ Does he have a drivers license? Yes No State I.D. card? Yes No Type of visa ____________________________________ If yes, in what state? ____________ Date issued ___________ Last renewed __________ Valid from _________________ to __________________ Does he own a motor vehicle? Yes No Is he registered to vote? Yes No If yes, date of registration ________________ In what state? _______________________ If yes, in which state? ____________ date ___________ Did he/will he file a California income tax return on his total income for: Has he voted within the last 15 months? Yes No Last calendar year? Yes No If no, what state? ___________________________ If yes, in which state? ____________ date ___________ This calendar year? Yes No If no, what state? ___________________________ Bank accounts (state/date established) Checking______________________________________ Did he/will he claim you as an exemption on his federal or state tax returns for: Savings _______________________________________ Last calendar year? Yes No This calendar year? Yes No

Students Mother:

___________________________________________________________________________ Does she claim to be a California resident? Mothers full name: Last First Middle Is she a U.S. citizen? ___________________________________________________________________________ Is she a U.S. permanent resident (PR)? Address: Number, Street, City, State, Zip If no, has she applied for PR status? Dates of Mothers Physical Presence in California: Continuously since birth If yes, does she currently hold a valid From _____________ To ______________ From ______________ To ______________ immigration visa status?

Yes Yes Yes Yes

No No No No

Yes No

If she claims California residence but has been absent from the state for more than six weeks during the last 12 months, please attach a statement explaining her absence. Does she have a drivers license? Yes No State I.D. card? Yes No If yes, in what state? ____________ Date issued ___________ Last renewed __________ Does she own a motor vehicle? Yes No If yes, date of registration _______________ In what state? ________________________ Did she/will she file a California income tax return on her total income for: Last calendar year? Yes No If no, what state? ___________________________ This calendar year? Yes No If no, what state? ___________________________ Did she/will she claim you as an exemption on her federal or state tax returns for: Last calendar year? Yes No This calendar year? Yes No

Alien registration # _______________________________ Date awarded ___________________________________ Type of visa ____________________________________ Valid from _________________ to __________________ Is she registered to vote? Yes No If yes, in which state? ____________ date ___________ Has she voted within the last 15 months? Yes No If yes, in which state? ____________ date ___________ Bank accounts (state/date established) Checking______________________________________ Savings _______________________________________

Do you authorize the University of California to release to your parents information regarding your residence file? Yes No Signature required: I declare under penalty of perjury under the laws of the State of California that the statements on both sides of this page and any attachments submitted by me in connection with the determination of my residence are, and each of them is, true and correct. Signature: _______________________________________________________________________________________________________________ Signed in: ___________________________________________________________________
city/county/state

Date _____________________________________

Privacy Notice: All of the information requested on this Statement of Legal Residence is required (by the authority of Standing Order 110.2(a)-(d) of the Regents of the University of California) for determining whether or not you are a legal resident for tuition purposes. Your registration cannot be processed without this information. The Office of the Registrar on campus maintains the requested information. You have the right to inspect University records containing the residence information requested on this form.