Select Term: Select College: Summer Orange Coast Fall Golden West Spring Coastline / Mil Year: STATEMENT OF RESIDENCE Per 5 CCR § 54012, each community college district shall use a residence questionnaire in making residence classifications. This document is used to gather information for the purpose of making a residency determination for persons who are not otherwise precluded from establishing residency who have:  Returned to California after a temporary absence or break in residence.  Persons who are or were active duty military or military dependents.  Persons who are minor dependents or legal financial dependents of a California resident. Legal residence is established by a combination of both intent and action. Each person has one and only one legal address. It is the place to which one returns in “seasons of repose”. In order to establish your legal residence for the purpose of attending a California public college or university, please complete this form and return it to your respective college’s Admissions and Records Office.

THIS FORM MUST BE SUBMITTED BY FRIDAY OF THE THIRD WEEK OF TERM IN WHICH YOU ARE SEEKING RECLASSIFICATION STUDENT INFORMATION (PLEASE PRINT LEGIBLY) 1. Name: Student ID: Last First M.I. 2. Birthdate: Age*: Birthplace: 3. LEGAL RESIDENCE. Enter the address for the place where you remain when not called elsewhere for labor or other temporary purpose. There can only be one legal residence.

Number and Street City State Zip 4. Current Mailing Address (if different from legal permanent residence) Phone: Number and Street City State Zip CITIZENSHIP/IMMIGRATION STATUS (5 CCR §54045) US Citizen Permanent Resident Temporary Resident Refugee/Asylum Student Visa DACA Other: Unknown A# Issue Date: Expiration Date: PHYSICAL PRESENCE AND INTENT (5 CCR §54022, §54024) (*If you are younger than 19, questions 1 -13 pertain to your parents. If you are 19 or older, these questions pertain to you.) 1. When did your present stay in California begin? Month Day Year 2. Do you rent, lease, or own your current address? Rent Lease Own Other 2A. If you selected “Other”, please select one of the following: Live with Parents Currently Homeless 2B. If you selected “Currently Homeless”, when did your displacement begin? Month Day Year 3. List your place of residence and inclusive dates within the last 3-years: Address From MM/YYYY To MM/YYYY

4. In what state did you pay state income tax for the previous year? 5. In what state(s) have you registered to vote in the previous two years? 6. In what state is your vehicle registered? From what state is your driver license issued? 7. Did you maintain a California bank account while residing out of state? No Yes If Yes, provide bank name and account number: 8. If you were absent from the state, what was the reason for your absence?

9. How long were you out of the state? 10. Did you intend to return to California? No Yes 11. Were you employed while outside of California? No Yes 12. Have you obtained a professional license in California? No Yes 13. List additional information which you feel may be pertinent to your residence status in the box below.

Page 1 of 2 Name: Student ID: FINANCIAL DEPENDENCE (5 CCR §54032, CA ED CODE 68044) 1. Have you been claimed as a dependent for tax purposes in the past two years? No Yes 1a. If yes, who is the person claiming you as a dependent? Relation? 1b. Address of the person claiming you as a dependent? 2. If your parents are divorced/separated, indicate the state where each parent lives:

Mother Father 3. Will/have your parent(s) claim(ed) you as a dependent exemption for federal and state tax purposes: For the current calendar year? No Yes For the past three calendar years? No Yes 4. Have you received or will receive more than $750 in financial assistance from your parent(s): In the current calendar year? No Yes In the past three calendar years? No Yes 5. Did/have you lived or will you live for more than six weeks with your parent(s) during: In the current calendar year? No Yes In the past three calendar years? No Yes 6. Are your parents California residents? No Yes If yes, please provide date of when their present stay in California began:

EDUCATIONAL HISTORY (5 CCR §54045.5) 1. Did you attend a California high school for three (3) or more years? No Yes FOR OFFICE USE If no, did you obtain at least three (3) years of high school credit? No Yes AB540 Eligibility 2. Were you awarded a high school diploma or equivalent from a California institution? No Yes Yes No 3. Are you current enrolled at Coastline, Orange Coast, or Golden West? 4. Have you been enrolled in any college or university outside our District within the past 24 months? No Yes Please list your educational institutions starting from the most recent: Dates of Attendance Fee Status School Name Location From MM/YY to MM/YY (Res, Nonres, Private, Online)

MILITARY (If Applicable) (5 CCR §54041, §54042, CA ED Code 68074 -68075.5) 1. Please select that box that applies to you: Spouse/Dependent Active Duty Veteran 2. Name of Serviceperson or Veteran: 3. Enlistment Date: Home of Record: 4. Are you currently stationed in California? No Yes When did your duty station begin? 5. What is your anticipated date of discharge? 6. Is the duty for education purposes only? No Yes

I declare under penalty of perjury under the laws of the state of California that the statements and documents submitted by me are true and correct. I further understand that all materials submitted by me for the purposes of residency determination become the property of the college. I understand that falsification or withholding pertinent data shall constitute grounds for disciplinary action under Coast Community College District regulations.

Student Signature Date FORM SUBMISSIONS NOTE: In keeping with standard business practices, we ONLY accept scanned documents in black and white PDF format as an attachment. Documents submitted are scanned into your records. We will NOT accept photo snapshots or photos of documents taken on cellphone cameras. We will NOT accept or process documents in the following formats: .jpg, .png, .bmp, .gif, .tif, .doc, .docx, .xls, .xlsx. COASTLINE COMMUNITY COLLEGE GOLDEN WEST COLLEGE ORANGE COAST COLLEGE ADMISSIONS AND RECORDS ENROLLMENT CENTER ENROLLMENT CENTER 11460 Warner Avenue, Fountain Valley, CA 92708 15744 Goldenwest Street, Huntington Beach, CA 92647 PO Box 5005, Costa Mesa, CA 92628 Fax: (714) 241-6288 ∙ Email: [email protected] Email: [email protected] Fax: (714) 432-5919 ∙ Email: [email protected] FOR OFFICE USE ONLY Determination: Resident Non-Resident Foreign Update Residency Eligible for: Military Exemption VACA DACA / AB540 CCC OCC GWC

Signature Date Comments:

Rev. 6/5/2017 Page 2 of 2