LOS ANGELES COMMMUNITY COLLEGE DISTRICT

SUPPLEMENTAL RESIDENCY QUESTIONNAIRE (Ver. 04/2020)

Reclassification requested for:

Winter Spring Summer Fall Year: ______

Student Name: _______________________________________________________________________

Student ID#: _________________________ Birthdate: __________________ Age: ____________

Phone Number: _______________________ LACCD Student E-mail: ________________________

Permanent Legal Address

Street: ______________________________________________________________________________

City: _________________________________ State: _______________ ZIP: _________________

1. I am a United States Citizen. YES NO

If YES, skip to Item 6.

2. I have a current nonimmigrant visa. YES NO

If YES, enter the following, then skip to Item 5.
Type: ____ Date Issued: _______ Entry Date: _______ Admitted Until: _______

3. I am a/an: (Check any that apply and provide appropriate documentation.)

a. Legal Permanent Resident
b. Applicant for Legal Permanent Residence
c. Asylee or Applicant for Asylum
d. Family Unity Program Beneficiary or Applicant
e. Temporary Protected Status (“TPS”) Beneficiary or Applicant
f. Violence Against Women Act (“VAWA”) Self-Petition Grantee or Applicant
g. Family Unity Program or LIFE Act Applicant
h. Applicant for “Withholding of Removal”
i. Other: ________________________

4. I applied for the status in Item 3 on: _______________________________

5. I have an Employment Authorization Document (e.g., Form I-766). YES NO

If YES, enter the following.
Provision of Law: _____________________ Card valid from: __________________

6. My present stay in California began on: ________________________________

7. I have lived at my present address continuously for the last two years. YES NO
If NO, list the places you have resided for the past two years.
From: __________ To: ___________ State/Country: ________________________
From: __________ To: ___________ State/Country: ________________________
From: __________ To: ___________ State/Country: ________________________

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8. I have engaged in the following activities: (Check any that apply.)
a. Registered to vote in a state other than California.
b. Petitioned for divorce in a state other than California.
c. Attended a non-California college/university as a resident of that state.
d. Filed as a non-resident for California state income tax purposes.

9. I am 19 years of age or older. YES NO

If YES, skip to Item 13.

10. My mother/guardian has resided in the following places in the last two years:
From: __________ To: ___________ State/Country: ________________________
From: __________ To: ___________ State/Country: ________________________
From: __________ To: ___________ State/Country: ________________________

My father/guardian has resided in the following places in the last two years:
From: __________ To: ___________ State/Country: ________________________
From: __________ To: ___________ State/Country: ________________________
From: __________ To: ___________ State/Country: ________________________

11. My parent(s) has engaged in the following activities: (Check any that apply.)
a. Registered to vote in a state other than California.
b. Petitioned for divorce in a state other than California.
c. Attended a non-California college/university as a resident of that state.
d. Filed as a non-resident for California state income tax purposes.
12. The following situation applies to me: (Check any that apply.)

a. I live with a parent who is a California resident.

Provide documentation of your parent’s California residence.

b. My parent, a California resident, pays court ordered support for me.

(Educ. Code § 68076.)
Provide documentation of (a) your parent’s California residence for the past year, and
(b) the court ordered support for you on a continuous basis for the past year.

c. I have lived with an adult California resident other than my parent who
has provided direct care and control over me for the past two years.
(Educ. Code § 68073, 5 C.C.R. § 54047.)
Provide documentation of (a) the adult’s California residence for the past year, and (b)
your living with this adult for not less than two years.

d. I am under 18 years of age, and within the last year my parent left
California (but for at least one year immediately prior to leaving was a resident
of California). (Educ. Code § 68070; 5 C.C.R. § 54030.)
Provide documentation of your parent’s California residence.

13. I attended an LACCD college in the past year. YES NO

If NO, skip to Item 15.

14. In this calendar year or in any of the three prior calendar years:
(Check any that apply.)
a. I will be, or have been, claimed as an exemption for tax purposes by my parent.
b. I will receive, or have received, more than $750 in assistance from my parent.
c. I will live, or have lived, for at least six weeks in my parent’s home.
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15. I have supported myself financially for at least the past year. YES NO
(Educ. Code § 68071; 5 C.C.R. § 54040.)
If YES, provide documentation of (a) your employment (e.g., W-2, paystub, benefits);
(b) your presence in California for the past year, and (c) your expenses for the past
year.

16. I am a current or former ward of the state (i.e., a foster youth), and was 19 YES NO
years of age or under at the time of enrollment. (Educ. Code § 68085.)
If YES, provide: (a) a copy of a juvenile dependency court document indicating foster
care in California’s child welfare system, or (b) documentation from county social
services confirming you were under the care of the Department of Social Services.

17. BOTH of the following statements apply to me: YES NO

I attended a California high school for three or more years; or I have three or more years
of high school coursework and attended a combination of California elementary, school
of three years or more; or I attended a combination of California high school, adult
school, and community college for the equivalent of three years or more.

I graduated with a California high school diploma (or expect to graduate with a diploma
and use the exemption in the following year) or have the equivalent (i.e., California-
issued GED, CHSPE); or I completed an associate’s degree from a California community
college; or I completed the minimum transfer requirements at a California community
college for transfer to the California State University or University of California.
(Educ. Code § 68130.5.)

If YES, complete an AB 540 Nonresident Tuition Exemption Request Form.

18. I am a member or veteran of the Armed Forces of the United States (or child YES NO
or spouse of such).
If YES, check if Items 19-23 apply, then go to Item 24.
If NO, skip to Item 24.
19. I am a child or spouse of a member of the Armed Forces of the United States stationed
in California on active duty. (Educ. Code § 68074; 5 C.C.R. § 54041.)
Provide: (a) a statement from the military person’s commanding officer or personnel officer that the
military person’s duty station is in California on active duty, or (b) that the military person is outside
of California on active duty after having been transferred immediately and directly from a California
duty station after the residence determination date. For a natural or adopted child or stepchild,
provide documentation that the child is a dependent for the military person for an exemption on federal
taxes.
20. I am a member of the Armed Forces of the United States currently stationed in California
on active duty. (Educ. Code § 68075; 5 C.C.R. § 54042.)
Provide: (a) a statement from your commanding officer or personnel officer that your assignment to
active duty in California is not for educational purposes; AND (b) evidence of the date of assignment
to California.
21. I was a member of the Armed Forces of the United States stationed in California on active
duty for more than one year immediately prior to being discharged (but not a dishonorable
or bad conduct discharge) within the last two years. (Educ. Code § 68075.5.)
Provide: (a) a statement from your commanding officer or personnel officer that your assignment to
active duty in California was not for educational purposes; and (b) a copy of your DD 214.
22. I am a veteran of the Armed Forces of the United States enrolling in college within three
years of discharge from a period of active duty of 90 days or more, and qualified to use
Montgomery GI Bill-Active Duty or Post 9/11 GI Bill benefits. (Educ. Code § 68075.7.)
Provide: (a) a copy of your DD 214, showing the date of your discharge from active service; OR (b) a
copy of a Certificate of Eligibility from the Department of Veterans Affairs (“VA”).
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23. I am a spouse or child of a veteran, am enrolling in college within three years of discharge
(or death in the line of duty) following a period of the veteran’s active duty of 90 days or
more, and qualified to use transferred Montgomery GI Bill-Active Duty or Post 9/11 GI Bill
benefits. (Educ. Code § 68075.7.)
Provide: (a) documentation that you are a dependent for an exemption for federal tax purposes; AND
(b) a Certificate of Eligibility from the VA.

24. I am a California public agency employee or law enforcement trainee, a YES NO

California public school employee, or a federal civil employee (or the spouse
or child of such).
If YES, check if Items 25-34 apply, then go to page 5.
If NO, check if Items 29-34 apply, then go to page 5.
25. I am a full-time California public school employee holding a valid credential.
(Educ. Code § 68078.)
Provide: (a) a statement from your public school employer confirming that your full-time position
requires certification qualifications for the current college year; AND (b) a copy of your credential.
26. I am full-time employee (or a child or spouse of such employee) of a state agency who
is assigned to work outside of the state. (Educ. Code § 68079.)
Provide documentation of the out-of-state assignment.
27. I am a federal civil employee (or a dependent of such employee) who moved to California
as a result of a military mission reassignment that relocated at least 100 employees. (Educ.
Code § 68084.)
Provide documentation of the employment and reassignment to California, and if applicable,
documentation that you are a dependent for an exemption for federal tax purposes.
28. I am a current law enforcement trainee, and a public agency intends to classify me as a
peace officer upon completion of coursework in the LACCD. (Educ. Code § 76140.5)
Provide (a) documentation of your passage of all other requirements of the hiring public agency, and
(b) documentation of the public agency’s intention to classify you as a peace officer.

29. I am one of the following:

- an Iraqi citizen or national (or the child or spouse of such) who was employed by or
on behalf of the United States government in Iraq; or
- an Afghan or Iraqi translator (or the child or spouse of such) who worked directly
with the Armed Forces of the United States; or
- an Afghanistan national who was employed by or on behalf of the U.S. government
or in the International Security Assistance Force in Afghanistan; or
- a refugee admitted to the United States under Section 1157 of Title 8 of the United
States Code. (Educ. Code § 68075.6.)
Provide a copy of your Special Immigrant Visa (SIV) or documentation reflecting your refugee status.
30. I am a graduate of a California school operated by the United States Bureau of Indian
Affairs. (Educ. Code § 68077.)
Provide a copy of your diploma from a BIA high school (e.g., Sherman Indian High School).
31. I am an amateur student athlete in training at the United States Olympic Training Center
in Chula Vista. (Educ. Code § 68083.)
Provide documentation of your status at the United States Olympic Training Center.
32. I (or my parents with whom I live) earn a living primarily through agricultural work for
hire in California. (Educ. Code § 68100, 5 C.C.R. § 54048.)
Provide documentation that you or your parent earn a living primarily by performing agricultural labor
for hire in California and that such labor has been performed in California for at least two months in
each of the prior two years. If your parent earns living through agricultural work for hire, please
provide documentation that: (a) your parent lives within the District; and (b) you were claimed as a
dependent for federal and state tax purposes if your parent earned sufficient income to incur a tax
liability.

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 33. I have a “T” (victim of human trafficking) or “U” (victim of certain crimes) nonimmigrant
visa. (Educ. Code § 68122.)
Provide a copy of the “T” or “U” nonimmigrant visa.
34. I am a U.S. Citizen living in a foreign country and whose parent/guardian was deported.
(Educ. Code § 76140(a)(5).)
Complete an SB 141 Nonresident Tuition Exemption Request Form.

DOCUMENTATION

The burden of proof is on the student to clearly demonstrate both physical presence in California and
intent to establish a permanent home in California. You must present the originals of at least two kinds of
documentation from the list, dated at least a year and a day before the start of the semester.

Federal and California state income tax forms from previous year showing a California home address
Documentation of purchase/lease of residential real estate in California covering a one-year period
California automobile registration
California voter registration
Utility bills (e.g., gas, water, power, phone) with a California address covering a one-year period
California driver’s license or California identification card
California vehicle registration
Active California bank account statements covering a one-year period
Selective Service registration with a California permanent address
Receipt of benefits from a California state agency covering a one-year period
California occupational license
Other documentation showing residence in California for the last year: ______________________

DECLARATION

I certify under penalty of perjury under the laws of the State of California that all of the information I have
provided on this form, and any presented documentation, is true and complete to the best of my knowledge.
I understand that falsification of documentation may constitute grounds for criminal prosecution and/or
student discipline, including but not limited to suspension or expulsion.

______________________________________________ _____________________
Student’s Signature Date

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 FOR OFFICE USE ONLY

Residence Code: _____________ Effective Term: ________________

Determined by: _______________ Date: ___________________________

Notes/Documents requested:

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