Parent Or Legal Guardian Supplemental Application For Virginia
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1
2Office of the University Registrar
DEADLINE: _____________
116 Alfred B. Rollins, Jr. Hall
Norfolk, VA 23529
757-683-4425
Date Received _____________
FAX: 757-683-5357
(office use)
PARENT OR LEGAL GUARDIAN
Supplemental Application for Virginia In-State Rates
INSTRUCTIONS TO PARENT OR LEGAL GUARDIAN
This form is a request for parental information to support an applicant’s claim to Virginia domiciliary status. If the applicant will be
claimed as a tax dependent or will be substantially supported by parent or guardian on the first day of the term in which he or she plans to
enroll, the parent or legal guardian must complete this supplementary application for Virginia status. The parent or guardian who is
supporting the applicant or upon whom the applicant is dependent must fill out this form. Without this information, it will be impossible to
determine whether the applicant is eligible for in-state tuition rates according to the domiciliary requirements set forth in Section 23-7.4 of
the Code of Virginia.
This form and all supporting documents must be returned within fourteen days of the initial decision notification date. A decision will
normally be reached within twenty-one days of receipt. Supporting documents that should routinely accompany this appeal include copies
of Virginia driver and vehicle liscenses. Virginia voter registration, and Virginia income tax forms. Applicants who are not U.S. citizens
should also submit a copy of the visa.
The purpose of this Virginia Domiciliary Application is to determine a student’s eligibility to receive in-state tuition benefits. Before
completing the application you should read Section 23-7.4 of the Code of Virginia to determine eligibility for in-state tuition benefits. The
statute and guidelines under which the university must operate are on reserve in the University Library. All forms are provided by the State
Council of Higher Education for use by all public institutions of higher education in the state.
In order to be eligible to receive in-state tuition benefits, an applicant must have been domiciled in Virginia continuously for at least
one year immediately preceding the academic term for which reduced tuition is sought. The applicant must also have the intent to remain
in Virginia indefinitely.
Requests for Virginia Domiciliary Status will not be retroactively approved for previous terms.
Name of Applicant ______________________________________________________________________________ Birth Date ______________
last
first
m.i.
maiden, family, other
Social Security Number ___________________________________ Term: Fall
Spring
Summer
Year ___________
1.
Name of Parent or Legal Guardian
________________________________________________________________________________
2.
Phone _________________________ Relationship to Applicant _________________________________________________
3.
Current Address (include Zip) _____________________________________________________________________________
4.
Home Address (if different) _______________________________________________________________________________
5.
Are you a citizen of the United States?
Yes
No If you are not a U.S. Citizen, please specify the type of VISA you hold:
_____________________________________Date issued ____________________ Expires ___________________________
6.
Have you been a legal domiciliary (permanent resident) of Virginia for the past twelve months?
Yes
No If no, state of
permanent residence ____________________________________________________________________________________
7.
Will the applicant be claimed as a dependent on your federal or state income tax return for the tax year prior to the date for which
in-state tuition rates are sought?
Yes
No
8.
Will you provide over half of the applicant’s financial support for the year prior to the date for which instate tuition rates are
sought?
Yes
No If so, in what form(s) will you provide this support (e.g., tuition, books, housing, clothing, transporta-
tion, medical and dental care, etc.?) _________________________________________________________________________
9.
If you are the applicant’s guardian, is this by court decree?
Yes
No
10.
Is either of the applicant’s parents deceased?
Mother
Father
Neither
11.
The applicant’s parents are:
Married
Separated
Divorced
Other
12.
List your address(es) for the two year period preceding the term in which the applicant will enroll. List current address first.
From/To (mo./yr.)
Street Address
City, State, Zip
_________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________
10/01
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