Instructions for Completion of the
Application for Classification as a Resident Student
IMPORTANT:
All information requested on this application must be provided. Incomplete information
and notarization may cause a delay or for the application not to be approved

Please print clearly, or type, all information on the form.

Notarization of the “Affidavit of Student” is mandatory. Notarization of the “Affidavit of
Parent or Guardian” is necessary only if there is a question on the student’s emancipation
from his/her parent.

There is space on the form for “Additional Remarks”. However, please attach any
information you feel is relevant to support your claim of residency.

When the application is completed, return it to the Office of Admission. The Director of
Admission will then review the application. In the interest of the applicant, the student may
be asked to supply additional information. The student will be notified of any action taken
on his/her application.
Note: Graduate Students must return the application to the Office of Graduate Studies.
The Director of Graduate Studies will review the application.

The application must be submitted two weeks prior to the first day of registration of a given
semester to guarantee consideration for that semester. A student or prospective student
who has been classified as a non-resident student and who fails to complete and submit an
Application for Classification as a Resident Student for fee purposes to the Director of
Admission (or Graduate Studies) within two weeks following registration of a particular
semester or session shall be deemed to have waived any alleged overpayment of fees for that
semester or session.

Undergraduate students return completed application to: Office of Admission, University of
Southern Indiana, 8600 University Boulevard, Evansville, Indiana, 47712. If you have any
questions, please call 812/464-1765.

Graduate students return the completed application to: Office of Graduate Studies,
University of Southern Indiana, 8600 University Boulevard, Evansville, Indiana, 47712. If
you have any questions, please call 812/465-7015.
Application for Classification as a
Resident Student at University of Southern Indiana
Please carefully read all rules, regulations, and instructions before completing. Please type or print.
Social Security Number_________________________
Student Status:
Undergraduate
Graduate
Name________________________________________________________________________________________________________
Last
first
middle/maiden name
Date of birth_________________ (mm/dd/yy) Age________
Are you a citizen or permanent resident of the United States?
Yes
No
On what date did you move to current address?_______________________Current Phone Number__________________________
Current Address________________________________________________________________________________________________
House or apt no., street
City
State
zip
On what date did you move to current address?______________________ Permanent Phone Number________________________
Permanent Address_____________________________________________________________________________________________
House or apt no., street
City
State
zip
Name of high school from which you graduated______________________________ City___________________________ State___
Year graduated from high school _________
Have you ever been enrolled at USI?
Yes
When were you first enrolled at USI? ____________________________ semester/year
No
Part-time
Full-time
If in the last 5 years you have lived in cities other than those listed above, please list cities and dates:
From (month/year)
To (month/year)
City
State
__________________________________________________________________________________
From (month/year)
To (month/year)
City
State
__________________________________________________________________________________
From (month/year)
To (month/year)
City
State
__________________________________________________________________________________
List your employers for the past 2 years:
From (month/year)
To (month/year)
Company
City
State
__________________________________________________________________________________
From (month/year) To (month/year)
Company
City
State
___________________________________________________________________________________
Part-time
Full-time
Part-time
Full-time
Marital
Status
Single
Married
Divorced
Separated
Is your spouse
enrolled at USI?
Yes
No
Spouse’s last semester
enrollment at USI: ______
Spouse’s Full Name _______________________________________
Spouse’s residence for past 5 years:
From (month/year)
To (month/year)
City
State
__________________________________________________________________________________
From (month/year)
To (month/year)
City
State
__________________________________________________________________________________
Do you claim to be emancipated?
Yes
No
If you answered “No” you must complete the questions pertaining to your parent or guardian.
If you answered “Yes” you can skip those questions.
Are you claimed as a dependent on
a parent’s or guardian’s federal income tax return?
Yes
No
Name of parent or guardian who
claims you as a dependent: ______________________________
Is the person you named as a parent or guardian a resident of Indiana?
Yes
No
If the parent or guardian has not lived in Indiana for the last 12 months what is his/her reason for living in Indiana? _________
_____________________________________________________________________________________________________________
Parent’s or guardian’s address for last 2 years:
From (month/year)
To (month/year)
City
State
_____________________________________________________________________________________________________
From (month/year)
To (month/year)
City
State
_____________________________________________________________________________________________________
Other colleges or universities you have attended:
College/Univ Name
From (month/year)
To (month/year)
City
State
______________________________________________________________________________________________________
College/Univ Name
From (month/year)
To (month/year)
City
State
______________________________________________________________________________________________________
College/Univ Name
From (month/year)
To (month/year)
City
State
______________________________________________________________________________________________________
Are you a veteran?
Yes
No
From what state did you enter
What was the date of last discharge from
the armed services? __________________ the armed services? ______________ (mm/dd/yy)
Are you now on
active duty in the
armed services?
Yes
No
What state is your
What is your expected date
home of record? _____________________ of discharge? ______________________ (mm/dd/yy)
To what state will you pay income
taxes and property taxes this year? ________________________
To what state did you pay income taxes and
property taxes last year? ___________________________
What state of residence did you give on your
federal income tax return this year? ________________________
What state of residence did you give on your federal
income tax return last year? __________________________
Do you have a driver’s license?
Yes
No
State which issued your current
Date license
driver’s license: ________________ was issued: ________________ (mm/dd/yy)
Other states in which you have held a driver’s license in the last 5 years:
State
From (month/year)
To (month/year)
_________________________________________________________________________________
State
From (month/year)
To (month/year)
_________________________________________________________________________________
State
From (month/year)
To (month/year)
_________________________________________________________________________________
Do you own an automobile?
Yes
No
Date of registration_________________
State in which your automobile is currently registered: ______________________
State in which your automobile was registered last year: _____________________
State in which you are currently registered to vote: __________________
Were you registered to vote last year?
Yes
No
Where? ___________________________________________
Do you (or your spouse) own any property in the State of Indiana?
Yes
No
If yes, give location and dates of ownership. _______________________________________________________________
Do you (or your spouse) own any property outside the State of Indiana?
Yes
No
If yes, give location and dates of ownership. _______________________________________________________________
What residence do you claim on any loan applications? Address
City
State
___________________________________________________________
Where do you live or spend your breaks when not attending a college or university including the University of Southern Indiana?
Additional Remarks:
AFFIDAVIT OF STUDENT
Social Security Number ______________________________________
I, _________________________________________________________, being duly sworn, state that all the information furnished in
the Application for Classification as a Resident Student at University of Southern Indiana is true, correct and complete to the best
of my knowledge.
___________________________________________________________
Signature of Student
_________________________________________________
Notary Public
_____________________________________________
My Commission Expires
AFFIDAVIT OF PARENT/GUARDIAN
(To be completed if the student has received within the past 12 months or is currently receiving any financial support from his/her
parent or guardian.)
I, ______________________________________________________, being duly sworn, state that I am now and have been since
_______________ a legal resident of the State of ___________________ and that I am employed by
________________________________________________ as ______________________________ and that I am the parent or legal
guardian of _____________________________________________ who has signed the foregoing Application for Classification as a
Resident Student at the University of Southern Indiana.
____________________________________________________________
Signature of Parent or Legal Guardian
______________________________________________
Notary Public
___________________________________________
My Commission Expires