NCTC Residency Questionnaire

Texas Higher Education Coordinating Board rule 21.25 requires each student applying to enroll at an institution to respond to
a set of core residency questions for the purpose of determining the student’s eligibility for classification as a resident.

PART A: STUDENT BASIC INFORMATION

Nguyen
______________________________________________________________________________________________________
Last First Middle

___________________________________________ _________________________
Social Security Number or Student ID Date of Birth

PART B: PREVIOUS ENROLLMENT

During the 12 months prior to the term for which you are applying, did you attend a public college or university in Texas
in a Fall or Spring term? q Yes q No
If yes, what was the name of the Texas public institution you attended______________________________________________

In which terms were you last enrolled? (Check all that apply) q Fall 20_____ or q Spring 20_____

For your last semester at a TX public institution, did you pay: q In-state q Out-of-state q Unknown
If you paid in-state tuition at your last institution, was it because you were classified as resident or were you a nonresident who
received a waiver? q In-state resident q Out-of-state with a waiver q Unknown
PART C: RESIDENCY CLAIM
Are you a resident of Texas? q Yes q No
PART D: ACQUISITION OF HIGH SCHOOL DIPLOMA or GED
1. (A). Did you graduate from high school or complete a GED in Texas? q Yes q No
(B). If you graduated from high school, what was the name and city of the school?
Name: _________________________________________________ City: ________________________________________
2. Did you live in TX the 36 months leading up to high school graduation or completion of the GED? q Yes q No
3. When you begin the semester for which you are applying, will you have lived in TX for the previous 12 months?
q Yes q No
4. Are you a q U.S. Citizen or q Permanent Resident (Status issued by US Citizenship and Immigration Service)
PART E: RESIDENCY FOR INDEPENDENT TAX PAYERS
1. Do you file your own federal income tax as an independent tax payer? q Yes q No
2. Are you claimed as a dependent or are you eligible to be claimed as a dependent by a parent or court-appointed legal
guardian? q Yes q No
3. If you answered “no” to both questions above, who provides the majority of your support?
q Self q Parent/ legal guardian or q Other (Explain) _____________________________________________

PART F: INDEPENDENT STUDENT
1. Are you a U.S. Citizen? q Yes q No
2. Are you a Permanent Resident of the U.S.? (Status issued by US Citizenship and Immigration Service) q Yes q No
3. Are you a foreign national whose application for Permanent Resident Status has been preliminarily reviewed? (You should not
have received a fee/filing receipt or Notice of Action (I-797) from USCIS showing your I-485 has been reviewed and has not
been rejected). q Yes q No
4. Are you a foreign national here with a visa or are you a Refugee, Asylee, Parolee or here under Temporary Protective Status?
q Yes q No If so, indicate which one: _______________________________________________________________
Residency Questionnaire - continued page 2

5. Do you currently live in Texas? q Yes q No (If you are out of state due to a temporary assignment by your employer
or other temporary purpose, please explain in Part H).
6. (A). If you currently live in Texas, how long have you been living here? Years _______ Months ______
(B). What is your main purpose for being in the state?
q Go to College q Establish/maintain a home q Work Assignment
7. If you are a member of the U.S. military, is Texas your Home of Record? q Yes q No
What state is listed as your military legal residence for tax purposes on your Leave and Earnings Statement? _____________
8. Do any of the following apply to you? (Check all that apply)
(A). Hold the title (Warranty Deed, Deed of Trust, or other similar instrument that is effective to hold title) to residential real
property in Texas? q Yes q No If yes, date acquired ______________________
(B). Have ownership interest and customarily manage a business in Texas without the intention of liquidation in the foreseeable
future? q Yes q No If yes, date acquired ______________________
9. For the past 12 months, have you: (Check all that apply)
(A). Been gainfully employed in TX? (Gainful employment requires an average employment of at least 20 hours per week for
one year or earnings equal to at least half of tuition and living expenses for one 9 month academic year.
Employment conditioned on student status such as work-study, the receipt of stipends, fellowships or research or teaching
assistantships does not constitute gainful employment) q Yes q No
(B). Received primary support through services from a social service agency for a period of at least 12 consecutive months?
q Yes q No
10. Are you married to a person who could answer “yes” to any part of question 8 or 9?
(A). If yes, indicate which question (and which part of the question) could be answered yes by your spouse.
Question: _________________________
(B). How long have will you have been married to the Texas resident prior to enrollment? Years _______ Months ______

PART G: PARENT or LEGAL GUARDIAN OF DEPENDENT STUDENT

1. Is the parent or legal guardian upon whom you base your claim of residency a U.S. citizen? q Yes q No
2. Is the parent or legal guardian a Permanent Resident of the U.S.? (Status issued by USCIS) q Yes q No
3. Is the parent or legal guardian a foreign national whose application for Permanent Resident Status has been preliminarily
reviewed? (You should not have received a fee/filing receipt or Notice of Action (I-797) from USCIS showing your I-485
has been reviewed and has not been rejected). q Yes q No
4. Is the parent or legal guardian a foreign national here with a visa or are you a Refugee, Asylee, Parolee or here under
Temporary Protective Status? q Yes q No If so, indicate which one: _________________________________
5. Does the parent or legal guardian currently live in Texas? q Yes q No
(If they are out of state due to a temporary assignment by your employer or other temporary purpose, explain in Part H).
6. (A). If the parent or legal guardian currently live in TX, how long have they been living here? Years _______ Months ______
(B). What is their main purpose for being in the state?
q Go to College q Establish/maintain a home q Work Assignment
7. If they are a member of the U.S. military, is Texas their Home of Record? q Yes q No
What state is listed as your military legal residence for tax purposes on your Leave and Earnings Statement? ______________
8. Do any of the following apply to your parent or legal guardian? (Check all that apply)
(A). Hold the title (Warranty Deed, Deed of Trust, or other similar instrument that is effective to hold title) to residential
real property in Texas? q Yes q No If yes, date acquired ______________________
(B). Have ownership interest and customarily manage a business in Texas without the intention of liquidation in the foreseeable
future? q Yes q No If yes, date acquired ______________________

9. For the past 12 months, has the parent or legal guardian: (Check all that apply)
(A). Been gainfully employed in TX? (Gainful employment requires an average employment of at least 20 hours per week for
one year or earnings equal to at least half of tuition and living expenses for one 9 month academic year. Employment
conditioned on student status such as work-study, the receipt of stipends, fellowships or research or teaching assistantships
does not constitute gainful employment) q Yes q No
Residency Questionnaire - continued page 3

(B). Received primary support through services from a social service agency for a period of at least 12 consecutive months?
q Yes q No
10. Is married to a person who could answer “yes” to any part of question 8 or 9?
(A). If yes, indicate which question (and which part of the question) could be answered yes by your spouse.
Question: _________________________
(B). How long have will you have been married to the Texas resident prior to enrollment? Years _______ Months ______

PART H. GENERAL COMMENTS

Is there any additional information that you believe your college should know in evaluating your eligibility to be classified
as a resident? If so, please provide information below.
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________

I understand that officials of North Central Texas College will use the information submitted on this form to determine my status
for residency eligibility. I authorize NCTC to verify the information provided. I agree to notify the proper officials of NCTC of any
changes in the information provided. I certify that the information on this application is complete and correct and I understand
that the submission of false information is grounds for rejection of my application, withdrawal of any acceptance, cancellation of
enrollment and/or appropriate disciplinary action.

STUDENT SIGNATURE: ___________________________________________________ DATE: _______________________

North Central Texas College does not discriminate on the basis of race, color, religion, sex, gender, national origin, age, disability or veteran status. With a few ex-
ceptions, state law gives the student the following rights regarding the information collected by NCTC: the student has the right to request to be informed about the
information, the right to receive the information, and the right to correct information that is incorrect. Information on this document is subject to change due to policy
changes by Federal, State, or North Central Texas College.

OFFICIAL USE ONLY:

Old Residency Code: __________ New Residency Code: __________

Residency Change Based On: _________________________________________

Processed By:____________________________ Date:________________

Campus: q GAINESVILLE q CORINTH q FLOWER MOUND q BOWIE q GRAHAM

MAY/2018