Application for Virginia Student Status Committee on Virginia Status • Office of Admission • P.O. Box 400160 • Charlottesville, VA 22904 Email: vastatus@virginia.edu • FAX: 434-­‐-­‐-­‐982-­‐-­‐-­‐2663 • Phone: 434-­‐-­‐-­‐982-­‐-­‐-­‐3391 • http://www.virginia.edu/provost/vastatus Instructions:
• Email or fax (not both) this form and copies of supporting documents (no originals) before the first day of the semester
for which you are applying for in-state tuition. If you cannot email or fax, mail the forms (contact information above).
• Incomplete or late applications will not be reviewed. The office will contact you if your application is incomplete.
• For an explanation of appeal process, see website.
Date of Application: ____________
Last Name: ____________________First Name: __________________Middle: _____________ Suffix: ____ Sex:
M
F
Current Mailing Address:
Zip:
Valid Until:
Permanent Mailing Address:
Zip:
Email Address:
Telephone Number(s): Home:
Work:
Date of Birth:
Citizenship:
(a)
(b)
U.S. Citizen
Permanent Residence
Political Asylum/Refuge
If you are not a U.S. citizen, please specify:
Date of Issue:
Other
Country of Origin:
Temporary Visa
Type of Visa:
Expiration Date:
Provide a copy of Visa or Green Card Date sent:
Semester at the University of Virginia for which you are applying for Virginia Status:
1.
, 20
(a) If this application is made in connection with an application for admission to U.Va., state which
school(s) you are applying to and the date(s) your applications were filed:
Specify whether your application for admission has been:
Approved
Denied
No Decision Yet.
(b) If you have previously applied for in-state privileges while enrolled at University of Virginia, indicate semester for which
privileges were sought:
(c) If you have ever previously been enrolled at a Virginia state institution of higher education, indicate your
official status classification during your last semester of enrollment: Check one:
Virginian
Non-Virginian;
Institution:
2.
(a) Your parent(s)’ / legal guardian’s domicile on your 18th birthday:
(b) Present domicile of parent(s) / guardian:
(c) How long has he / she been so domiciled:
(d) Have you been, or will you be, claimed as a tax dependent on your parent’s or legal guardian’s income tax return for the
tax year prior to the date of alleged entitlement?
YES
NO
(e) Did your parent(s), spouse or legal guardians provide you with over half your financial support for the tax year prior to the
date of alleged entitlement?
3.
YES
NO
Specify periods during which you have resided in Virginia and addresses at which you have resided, beginning with your
current address: From
Month/Year
To
Month/Year
Address
If residence in Virginia has not been continuous, give reasons for absences:
4.
If you have lived outside of Virginia at any time during the last five years, specify periods during which you
have resided outside of Virginia, and addresses at which you have resided:
From
Month/Year
5.
Address
Employment: List any employment during the last three years
6.
To
Month/Year
From
Month/Year
To
Month/Year
Employer
Address
Hrs/Wk
Salary
Education: List all high schools, colleges & universities attended; indicate classification (resident or nonresident)
at public institutions
From
Month/Year
Month/Year
School
Degree
Classification
7.
Attendance at the University of Virginia:
(a) Date of first enrollment at U.Va.:
(b) School and year at U.Va. (e.g., Law II):
(c) Expected date of graduation:
Degree:
(d) If your attendance has not been continuous, provide explanation:
8.
Post-University of Virginia plans:
(a) Specify any permanent post-graduation employment already accepted by you, and its location:
(b) Have you solicited permanent employment with employers located outside Virginia?
Specify:
YES
NO
(c) If you intend to enroll in school for further study after graduation, list schools to which you have
applied or intend to apply:
9.
Taxes:
(a) Have you paid a state income tax to any state during one or more of the last three years?
YES
NO
lf yes, to which state (s) and for what year(s)?
(b) If you filed a state income tax return in Virginia last year, did you file a resident or a non-resident tax return?
(Check One)
Resident
Non-Resident
(c) Did you file a joint return last year?
YES
NO
(d) If military, did you pay state income tax on your military salary to the State of Virginia last year?
YES
NO
YES
NO
(e) State currently being claimed for income tax purposes:
Email or fax a current copy of a Leave and Earnings Statement reflecting Virginia withholding.
Date sent: ______________
10.
Driver's License:
(a) Do you hold a valid Virginia's driver's license?
When were you first licensed in Virginia?
, 20
Date of last renewal?
, 20
(b) If you do not now have a Virginia driver's license, from which state do you hold a driver's license?
Date acquired:
Date of last renewal:
(c) No driver's license anywhere:
11.
Motor Vehicle Registration:
(a) Do you own or operate a motor vehicle?
(b) In whose name is it registered:
YES
NO
Relationship:
(c) In what state is the vehicle registered:
If in Virginia, when was it first registered here?
If registered in another state, specific: Registration Date:
12.
Last Renewal Date:
Voting:
(a) When and in what state did you last register to vote: Date:
(b) When and in what state did you last vote: Date:
(c) Not registered to vote anywhere:
13.
14.
State:
State:
Do you own real property in any state?
Co-owner(s):
Relationship:
Location:
Date of Purchase:
Do you receive any type of financial aid?
(a) If yes, specify the name of the lending institution and its location:
(b) Did you have to claim legal residence in that state in order to qualify, for the aid?
YES
NO YES
NO
YES
NO
YES
NO
YES
NO
If yes, specify date of award:
15.
Have you received any financial support from your parents, spouse or legal guardian in the past year?
If yes, please specify amount received:
16.
Do you have a checking or passbooks savings account?
Location of account:
Date opened:
17.
Military service:
YES
(a) Are you a member of the armed forces?
(b) Is your parent(s), spouse or legal guardian a member of the military?
YES
(c) Are you, your parent(s), spouse or legal guardian discharged from the military?
If yes, provide proof of discharge. Date sent:
(d) If you, your parent(s), spouse or legal guardian are in the military, please provide the following information:
Applicant
1.
Date of entering service
2.
3.
Home of record on entering
Changes in home of record
(date and states)
State claimed for tax purposes on
entering
Changes in state claimed for tax
purposes
(dates and states)
4.
5.
6.
Duty station
Expected date of discharge
18.
Parent / Spouse / Legal Guardian
(a) Are you claiming entitlement for in-state educational privileges as a person who resides outside of Virginia but commutes
YES
NO
to work in Virginia and pays income tax to Virginia on all income earned in the Commonwealth?
State of Residence:
Employer:
(b) Are you claiming eligibility as a dependent of such an individual?
YES
NO
Name:
Relationship:
State of residence:
19.
NO
NO
Employer:
Are you claiming entitlement to a special tuition rate as the employee of an agency or institution that has a special arrangement
contract with this University?
YES
NO
YES
NO
Name of employer:
20.
21.
22.
When and why did you initially move to Virginia?
When do you believe you first became domiciled in Virginia?
Do you presently have the intention of remaining indefinitely in Virginia following graduation?
If yes, set forth any objective evidence to support your claim which has not been covered in the preceding questions:
23.
If you have previously applied for in-state classification in any state, please specify which state and when:
20
If Virginia, specify the approximate date of application:
20
;
and forward copies of any pertinent correspondence with the Committee which you still retain.
Please provide additional information or explanation of any of your responses here:
I hereby certify that the information given is true and accurate. I also understand that if I provide erroneous information in an attempt to
evade payment of out-of state fees, I will be charged out-of-state fees for each term attended and be subject to dismissal from the
University.
Student’s signature
Date
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