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CSU RESIDENCE QUESTIONNAIRE
RETURN THE COMPLETED FORM TO THE CAMPUS OFFICE OF ADMISSIONS AND RECORDS
The information requested is deemed relevant and necessary to a proper determination of your residency status for tuition purposes pursuant to the
California Education Code Section 68000 et seq. and California Code of Regulations 41900 et seq. Your completed application will help us determine
your eligibility. Failure to answer all questions may cause you to be classified as a nonresident. You may submit additional information you believe will
establish your California residency. Questions about residency requirements should be referred to a campus residence specialist.
Instructions: Please complete a separate questionnaire for each campus. Only one term and one campus may be selected per
questionnaire and all fields must be completed or questionnaire will be returned to you unprocessed.
Avoid entering personal information on public computers and/or public wireless access points.
Classified as a nonresident for a previous term Yes. Please complete Part A, B, C, D (if applicable), and E
No. Please complete Sections A, B, D (if applicable), and E (Newly admitted students only)
Term: Fall Winter Spring
PART A: STUDENT INFORMATION
Summer Year
Campus
Specify Campus
Name
Phone Number
Last Name First
E- mail
Middle
Student ID No.
Birthdate /
Month Day
/ Birt
Year
hplace
Permanent Legal Address
Street Address
City State ZIP
Did you attend a California school? Yes No (If yes, you may be exempt from payment of nonresident tuition under AB 540.)
Residence Determination Dates
PART B: RESIDENCE DETERMINATION DATE
Quarter Calendars
Semester Calendars
Check the box that applies to you and provide the requested information
Fall ..............................September 20
Fall .......................September 20
Winter ............................... January 5
Winter ........................ January 5
If you will be 19 years of age or older by the residence determination date,
Spring......................................April 1
(Stanislaus only)
check here and answer 1 through 11 as it applies to you.
Summer ...................................July 1
Spring ...................... January 25
Summer........................... June 1
If you will be younger than 19 years of age by the residence determination date,
check here and answer 1 through 11 as it applies to the natural or adopted parent with
CalState TEACH
whom you most recently resided and whose name and whereabouts you will provide below.
Stage 1......................September 20 Stage 3.............................. June 1
Name
Stage 2............................ January 5 Stage 4...................September 20
Relationship
Present actual whereabouts
Foster Youth Please check the box that applies to you and complete Part A (answer 1 through 11 as it applies to you), B, C, D (if applicable) and E.
List the State where you were under the care of the Department of Social Services (e.g. California):
I have been in the foster care for at least 12 consecutive months after reaching the age of 10.
I am in a current foster care out-of-home placement order by a juvenile dependency court.
I was still in a foster care out-of-home placement, ordered by the juvenile dependency court when I reached my 18th birthday.
Provide the following information: (a) a copy of a juvenile dependency court document indicating foster care in the child welfare system; or
(b) documentation from county social services confirming you were under the care of the Department of Social Services.
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Student Name Student ID
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QUESTIONS 1 THROUGH 11
1. What state do you regard as your permanent home?
2. If California, when did your present stay begin / /
Month Day Year
3. Employed in California in the past year? Yes No
Employer(s) From / / To / /
Month Day Year Month Day Year
Employer(s) From / / To / /
Month Day Year Month Day Year
4. Have you ever registered to vote? Yes No (List all states where registered and date of registration)
State
Date registered / / Last Voted / /
Month Day Year Month Day Year
State Date registered / / Last Voted / /
Month Day Year Month Day Year
5. Do you possess a driver’s license and/or ID Card? Yes No (If yes, list state and issue dates)
State
Date Issued / / Previous State Date Issued / /
Month Day Year Month Day Year
6. Current registration of all vehicles owned or operated
State
Date Issued / / State Date Issued / /
Month Day Year Month Day Year
7. Are all personal effects located in California? Yes No If “no,” attach explanation on a separate piece of paper.
8. State where last three state income tax returns filed on total income and year covered by each.
Year State Year State Year
State
9. Address shown on most current W-2
Please answer the following questions if you currently or previously owned, rented or leased a residence.
Please list all residences during the past three years.
10. Purchased, leased or rented
Date / / to Date / / Location
Month Day Year Month Day Year City and State
Date / / to Date / / Location
Month Day Year Month Day Year City and State
Date / / to Date / / Location
Month Day Year Month Day Year City and State
11. Active California banking account(s) Opened / /
Month Day Year
Opened / /
Month Day Year
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Student Name Student ID
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PART C: IS ONLY FOR RECLASSIFICATION OF CURRENT STUDENTS WHO HAVE BEEN CLASSIFIED AS A NONRESIDENT IN A PREVIOUS TERM
I have been classified as a nonresident in a previous term and I am requesting reclassification. Yes No
Has there been a change in your citizenship, permanent residency, visa or other status? Yes No If yes, please explain in the box below, provide documentation and
answer questions 1-8 below.
If yes, please answer all of the following questions (1-8). Failure to provide complete information may result in nonresident classification (Ed Code 68041).
1. Will your parent(s) claim you as a dependent exemption for state and federal tax purposes for the current calendar year?..............................................Yes No
2. Were you claimed as an exemption for state and federal tax purposes by your parent(s) in any of the past three calendar years?...................................Yes No
If yes, please state year(s)
Year Year Year Year
3. Have you received or will you receive more than $750 in financial assistance from your parent(s) in the current calendar year? ......................................Yes No
4. Did you receive more than $750 in financial assistance from your parent(s) during any of the three past calendar years?.................................................. Yes No
If yes, please state year(s)
Year Year Year Year
5. Have you lived or will you live for more than six weeks with your parent(s) during the current calendar year?.................................................................... Yes No
6. Did you live for more than six weeks with your parent(s) during any of the three past calendar years? ..............................................................................Yes No
If yes, please state year(s)
Year Year Year Year
7. List all places you have lived prior to your most recent arrival in California, the dates you lived in each place and the parent with whom you resided.
If you need more room, please attach an explanation on a separate sheet of paper.
From
/ / To / / State or Country Parent you resided with
Month Day Year Month Day Year
From / / To / / State or Country Parent you resided with
Month Day Year Month Day Year
8. Source(s) of financial support during the past year
PART D: EXCEPTIONS/EXEMPTIONS Military AB 540 *Other Exemptions/Exceptions (choose applicable exception
from www.calstate.edu/residency). If you are not eligible for resident classification, you still may be eligible for an exemption or exception from payment of nonresident
tuition. *Other exceptions/exemptions are limited to those listed at www.calstate.edu/residency
Military
Have you ever served in the United States military? Yes No
Are you a dependent (child/spouse) of a person who served in or is currently serving in the U.S. Armed Forces? Yes No
If yes,
Date joined
/ / From which state Date separated from active duty, if any / /
Month Day Year Month Day Year
What is your home of record?
What was your last permanent duty station? From / / To / /
Month Day Year Month Day Year
I served in the U.S. Armed Forces and am eligible to receive educational assistance under either the Montgomery GI Bill
®
or Post-9/11 GI Bill
®
educational benefits
program. I reside in California and my first day of class in the CSU will fall within 36 months from the date of discharge from active duty service of 90 days or more.
Provide: (a) a copy of your DD Form 214 (DD214) showing the date of your discharge from active service; and (b) a copy of a Certificate of Eligibility from the
Department of Veterans Affairs (VA).
I am a dependent of a person who served in the U.S. Armed Forces and am eligible to receive educational assistance under the Post-9/11 GI Bill educational benefits
program. I reside in California and my first day of class will fall within 36 months of former service member’s discharge following a period of activity duty of 90 days
or more.
Provide: Certificate of Eligibility from the VA.
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I am a dependent of an active duty service member of the U.S. Armed Forces. I reside in California and have received transferred benefits under the Post-9/11 GI Bill.
Provide: Certificate of Eligibility from the VA.
I am a dependent of a service member of the U.S. Armed Forces who died in the line of duty after September 10, 2001. I reside in California and am eligible to receive
veteran’s educational assistance.
Provide: Certificate of Eligibility from the VA.
I am a service member or the dependent of a service member of the U.S. Armed Forces who is stationed in California.
Provide: Permanent Change of Station orders or a statement from the service member’s commanding officer.
I served in the U.S. Armed Forces on active duty in California for more than one year and am enrolling within two years of discharge from a California military base.
Provide: (a) copy of your DD214; (b) evidence of being station in California upon separation from service; an affidavit to the institution at which you are enrolling stating
your intent to establish residency in California as soon as possible.
I currently participate or will participate in the VA’s Vocational Rehabilitation program.
Provide: VA Form 28-1905.
GI Bill
®
is a registered trademark of the U.S. Department of Veterans Affairs (VA). More information about education benefits offered by VA is available at the official U.S government Web site at
https://www.benefits.va.gov/gibill.
Note: If you currently do not have the necessary documentation to show that you qualify for a military exemption, you will be charged nonresident fees. Once the CSU campus receives and reviews
your documentation, fees will be adjusted as appropriate.
Education Code § 68130.5, as amended, commonly known as AB 540
Certain nonresident students (including U.S. citizens, permanent residents, and undocumented individuals) who have attended, graduated, or achieved the equivalent from a
California school (elementary school, secondary school, adult education, community college) may be exempted from paying nonresident tuition. Such students must remain
classified as “nonresidents” for residency classification and financial aid eligibility purposes.
You must meet the Attendance Requirement and Graduation/Degree requirements (check boxes that apply).
Attendance requirement (must meet one):
I have 3 years of attendance at a California high school.
I have 3 or more years of high school coursework and 3 years of attendance in California elementary schools, California secondary schools, or a combination
of California elementary and secondary schools.
I attended or attained credits at a combination of California high school, California adult school, and California Community College for the equivalent of
(3) years or more.
Graduation/Degree Requirement (must meet one)
I have graduated or will graduate (before the first term of enrollment at the CSU) with a California high school diploma or the equivalent (i.e., California-issued GED,
CHSPE).
I completed or will complete (before the first term of enrollment at the CSU) an associate’s degree from a California Community College.
I completed or will complete (before the first term of enrollment at the CSU) the minimum requirements at a California Community College for transfer to the
California State University.
If you checked at least one box in the Attendance and Graduation requirement questions, you may be eligible for California nonresident tuition exemption.
Please complete and submit the California Nonresident Tuition Exemption Request (commonly known as the affidavit). Please complete a separate form for each campus
Each campus will request additional information (e.g. high school transcripts).
PART E: CERTIFICATION – to be read and signed by all students completing this form
The burden of proof is on the student to clearly demonstrate both physical presence and intent to remain indefinitely in California. Students seeking reclassification of
nonresident status must also demonstrate financial independence. You are required to present evidence in accordance with the Education Code and Code of Regulations
referenced above.
Certification – To be read and signed by all applicants to certify the accuracy of the information provided.
I certify under penalty of perjury that the foregoing statements and any other information submitted by me in connection with the determination of my residency are true,
complete, and accurate. I understand that my residency determination will be based on the facts stated in this questionnaire and the documents I provide. If I receive classification
as a California resident or an exception or exemption, I promise to notify the residence specialist if any of the facts stated in this questionnaire change. I authorize release of any
information submitted by me in connection with my application for admission and determination of residency to any person, firm, corporation, association or government, whether
federal, state, local, or foreign, but only as necessary to verify or explain the information, to obtain pertinent records, or in connection with perjury proceedings.
Signed at
City and County Applicant Signature Date
FOR CSU CAMPUS USE ONLY
Form Processed By:
Date Approved Denied
June 2019
(rev. 06/19 10787)
OFFICE OF ADMISSIONS
1000 East Victoria Street ● Carson, CA 90747
(310) 243-3645
Residence Reclassification Checklist
Name: ________________________
____________ Date: _______________________________
CSUDH ID #: ______________________________ Term of Consideration: _________________
For students who are already attending the University, and are eligible for reconsideration of their residence for tuition purposes.
This form is to be used to assist in the process of collecting the required documentation for your residency packet. Please follow the
checklist below to assure you’re submitting a complete packet.
**Please check off all the items you are submitting with the packet. **
Semester
Residence Determination Date
Fall Semester
September 20
th
Spring Semester
January 25
th
Summer Semester
June 1
st
1. Complete Residence Reclassification form, must complete Sections A, B, C, D (if applicable), and E.
2. Include at least ONE of the following documents:
Most current California State Tax Return (540 form or 540c form).
Verification of Employment or Check Stubs for 12 months - Check stubs must show your name and California home
address. Verification of employment letters from employer’s need to be on company letterhead, and include full name,
California home address and dates of employment. Please note, employment must be in California.
Rental /Lease Agreement - Rental lease agreements must be up-to-date, and not expired. Student’s name must be
evident on the contract in order to be considered for review. Please note, your lease agreement must show that you
have been in California for a minimum of a year, from the residency determination date.
Mortgage Statements - Must show name, California home address for 12 months.
3. Include at least FOUR of the following documents:
Bank Statements or Bank Letter - Bank statements must show your name and California home address for a minimum
of one year. Letters from banks must on a bank letterhead, include your name, California home address, and the date
you opened the account. The letter must show the branch location, and be present in California.
4. Provide proof of financial independence by submitting the following:
CA State
Taxes, Check Stubs, and /or Bank Statements
NOTE: Students under the age of 26 may be required to submit copies of your parent’s Federal Tax Forms for up
to three years prior to residence determination date.
5. If you are a citizen of another country, submit paperwork on your current immigration status such as:
Visa - Copy of the front and back must be provided.
6. Once all documents have been collected please submit the required documents to the Admissions and Records Office either
in person, mail, or by *email at [email protected]. *All documents must be in PDF form if submitted by email.
*All required documents must be submitted for review by the Residence Determination Deadline.
Office of Admissions
CSU-Dominguez Hills
California DMV vehicle registration - Vehicle registration needs to be current and not expired.
California Identification card or Driver’s License - Must be valid and not expired.
Most current W-2 Form - Must show California home address.
California Voter Registration - Voter registration must show name and California home address.
