1. Last NameFirst NameMI
Social Security NumberPhone Number
Other names, if any, under which you have been employed:
2. Current address while attending this institution:
Street and Number
City State Zip/Postal Code
3. Permanent address: Street and Number
4. For which semester are you applying for residency? Semester Fall Spring Summer Year
Have you previously applied for residency at a Kansas Regents' institution? Yes No
If yes, indicate institution and year you applied
Have you read the accompanying regulations pertaining to Residence for Fee Purposes? Yes No
5. Date of Birth Place of Birth
6. Are you a CITIZEN of the United States? Yes No If no, have you been granted Immigrant or Permanent Resident status by the U.S. Immigration & Naturalization Service? Yes No
If no, indicate type of VISA If yes, attach a copy of your Alien Registration card.
If no, indicate type of VISA
If yes, attach a copy of your Alien Registration card.
7. When did your current period of physical presence in Kansas begin? Month/Day/Year
Have you lived in Kansas continuously since this date? Yes No
8. Where did you live before moving to Kansas (before the date above)?
City/State/Countryfrom to
9. Where did you spend the previous summer? (provide specific dates)
10. Marital status: Single Married Separated Divorced Widowed
If married, provide the following: Date of marriage (month/day/year) Legal name of spouse
Complete CURRENT address and telephone number of spouse: Address
Phone You may be required to provide a copy of your marriage certificate.
11. Parental Information.
a. Father's full legal nameAddress
b. Mother's full legal nameAddress
c. If your parents are divorced, which parent has legal custody of you? MotherFather
d. From which parent do you receive the preponderance of your support? MotherFather
e. If neither parent is living, or if you have a guardian, give the name and address of guardian.
NameAddress
If requested, a certified copy of the court order establishing custody or guardianship must be presented. Guardianships established for the sole purpose of qualifying the ward for resident fees will not be honored.
f. Did your parents or guardian file a Kansas State Resident Income Tax return for the last tax year? Yes No
12. Have you been licensed or certified to practice a profession in Kansas? (doctor, lawyer, nurse, teacher, etc.) Yes (identify which one) No
13. Where are you currently registered to vote? (city and state)
When did you last register to vote in Kansas?
14. List all colleges you have attended in the last five years, with dates of attendance, credit hours earned, and student resident status (for fees) at each institution:
15. Employment record: List all employment since your latest period of residence in Kansas began (latest employment first, list periods of full-time and part-time employment with the same company separately):
16. Financial Support and Expenses.
a. Financial Support. List all financial support for the past twelve months. Include scholarships, loans, grants, employment, personal savings, and gifts from friends or relatives. NOTE: National funds such as trusts, stocks, mutual funds and governmental benefits should be listed. Provide documentation of all support listed below: current Kansas income tax returns, bank statements, savings account statements, current pay stubs, financial aid offers, trust, stock, mutual fund documents, statements of support by friends, family or relatives, etc.
Total Income
b. List all expenses for the past twelves: Note: If you share expenses, list only your portion of these expenses.
Housing costs Total for past 12 mos.
Food costs Total for past 12 mos.
Phone, electric, gas, etc. per month Total for past 12 mos.
Health care costs, incl. insurance Total for past 12 mos.
Vehicle and transportation costsTotal for past 12 mos.
Clothing, laundry and entertainmentTotal for past 12 mos.
Tuition and Fees per term: SummerFallSpring Total
Books & supplies per term: SummerFallSpring Total
Total Expenses
c. Do you have health insurance? Yes No
If yes, who pays the cost? If no, who pays the cost of your health care? You may be required to provide documentation to substantiate all listed expenses.
If yes, who pays the cost?
If no, who pays the cost of your health care?
17. With what state did you file your last STATE income tax return? (year and state)
18. Were you claimed as a dependent on another person's last federal income tax return?
Yes, year No Who? nameRelationship to you Complete address
Yes, year No
Who? nameRelationship to you
Complete address
19. Was Kansas personal property tax paid on the vehicle you currently own or drive?
a. No b. Yes If yes, what year? c. No vehicle in my possession
20. Provide information concerning the present license plate on the vehicle you own or drive.
a. State License plate number Date plate obtained b. Vehicle owned by whom? c. No vehicle in my possession
a. State License plate number Date plate obtained
b. Vehicle owned by whom? c. No vehicle in my possession
21. What state issued your current driver's license?
License Number Date issued
22. Why did you come/return to Kansas?
23. Other than being physically present in Kansas, what relationships or obligations connect you to the state, making it your permanent home?
24. How long do you plan to remain in Kansas?
25. What are your plans after your academic work here is completed?
If you feel that there are other pertinent facts not covered by any of the previous questions/answers, please write them on a separate sheet of paper and attach it to this form.
I CERTIFY THAT THE INFORMATION GIVEN ON THIS APPLICATION IS CORRECT. I UNDERSTAND THAT FALSIFIED INFORMATION CAN RESULT IN FINANCIAL OBLIGATION (NON-RESIDENT FEES) TO, AND DISMISSAL FROM THIS INSTITUTION AND THAT MAKING A FALSE WRITING IS A FELONY UNDER KANSAS LAW (K.S.A. 21-3711). I ALSO UNDERSTAND THAT INFORMATION FROM MY APPLICATION FOR ADMISSION AND OTHER UNIVERSITY RECORDS WILL BE CONSIDERED A PART OF THIS APPLICATION.
Date_________________ Signature (in presence of a notary public)____________________
Notarization:
Subscribed and sworn to/affirmed before me this_____ day of ___________________, 19____, at
(city) ______________.
My appointment expires:___________________