WSU - Residency Information

Request to Change Residency Status for Tuition Purposes

[ Request to Change Status | Ways to Qualify | How to Document ]
[ Change Request Form Instructions | Residency Change Request Form ]
[ Residency Change Request Form - PDF Format - Requires Adobe Acrobat Viewer | Criteria ]
[ Residency Information Home ]

Requested documentation must be submitted with application.

Submit to: Office of the Registrar
3640 Colonel Glenn Hwy.
Dayton OH, 45435 - 0001
(937) 775-5588
FAX: (937) 775-5597

Full legal name (Please Print) : ___________________________

Social Security number: ___________________________

Date of birth: ___________________________

Phone number: ___________________________

E-mail address: ___________________________

1. Quarter for which you are requesting reclassification as a resident: ____________

New student
Currently enrolled student
Former student—Last quarter attended: ________________

2. Circle the one rule among the following Rules of Residency under which you believe you qualify.
C1 C2 C3 E1 E2 E3 Senate Bill 53 E3

3. Marital status: Single Married (month and year: ____________)

If married, does your spouse live in Ohio? Yes No

If yes, give dates. From ___________ To ____________

Does your spouse work full-time in Ohio? Yes No

Number of dependents (including self): ________________

4. Are you on active military duty in Ohio or a dependent of such a person?
Yes No

5. Are you a citizen of the United States? Yes No

If no, what type of visa do you hold? Attach copy of visa.
Permanent resident alien
(Date and alien registration number: _____________________)
Student visa
Other (specify): _____________________

6. In what state are you registered to vote? ____________ Attach copy of voter registration card.

7. Have you filed an Ohio personal income tax statement for the past twelve months? Attach copy of most recent return.
Yes, for year ______ No

8. Do you have a driver’s license?	Yes No
Is it from Ohio? Attach copy.	Yes No
Do you own or have use of a car?	Yes No
Is it titled in your name?	Yes No
Is it currently registered in Ohio? Attach copy.	Yes No
Do you have car insurance?	Yes No
Is this your insurance policy?	Yes No
If no, name/relationship/state of person with insurance under which you are covered _____________________________________________

9. Dates you have lived in Ohio (choose one):
Birth to present
From (Month/Year):________ / ________Present
Never

10. Beginning with your current address, list your addresses for the past 12 months. Attach appropriate documentation of Ohio addresses (e.g. lease, closing statement, or notarized letter from property owner certifying length of residence).

Address:

Street:	___________________________
City:	___________________________
State:	___________________________
Zip:	___________________________

Dates from (Month Day Year) ______________________to present

Occupation (Student/Work) ___________________________
(If work, give the name of your employer)

If student:
Full-time
Part-time
Paid nonresident fee

If employed:
Full-time
Part-time

Address:

Street:	___________________________
City:	___________________________
State:	___________________________
Zip:	___________________________

Dates from_____________to _____________

Occupation (Student/Work) ___________________________
(If work, give the name of your employer)

If student:
Full-time
Part-time
Paid nonresident fee

If employed:
Full-time
Part-time

Address:

Street:	___________________________
City:	___________________________
State:	___________________________
Zip:	___________________________

Dates from_____________to _____________

Occupation (Student/Work) ___________________________
(If work, give the name of your employer)

Other: has lived in Ohio from (Month Year )__________to(Month Year) ____________
or

has never lived in Ohio.

Where do they live?_____________________
Relationship___________________________

If you are a dependent student: attach photocopy of page showing dependent section of latest tax form of the person claiming you. Also substantiate residency of person declaring you as an exemption by verifying he/she has lived in Ohio the past 12 months. Will this person claim you on the next year’s tax return?

Yes No

12. Independent students applying for either Residency Rule C-2 or E-1 who are not employed full time in Ohio, must complete this section. C-2 applicants must list all income and expenditures for the 12-month period preceding the quarter of application for residency. E-1 applicants must list employment income and expenditures since (s)he has lived in Ohio. Fully document all sources of income by providing clear photocopies. If listing support in the parent/guardian or relatives/friends sections, indicate the contributor's state of residence and length of time lived there.

Income

Student’s employment	$_______________
Spouse’s employment	$_______________
Savings	$_______________
Scholarships	$_______________
Grants	$_______________
Loans	$_______________
Fee waiver	$_______________
VA benefits	$_______________
Social Security	$_______________
Parent/Guardian	$_______________
State of residency	________________
Length of time	________________
Relatives/Friends	$_______________
State of residency	________________
Length of time	________________
Other	$_______________
Total	$_______________

Expenditures

Fees (Tuition)	$_______________
Books/Supplies	$_______________
Food	$_______________
Rent/Housing	$_______________
Utilities	$_______________
Travel	$_______________
Clothing	$_______________
Laundry	$_______________
Auto payment	$_______________
Auto insurance	$_______________
Other insurance	$_______________
Credit card	$_______________
Other	$_______________
	$_______________
	$_______________
Total	$_______________

13. Oath
I, the undersigned, do affirm that the information supplied on this residency application is true and complete.

X________________________________________
Signature of student

Date______________________________________

Office Use Only

Residency Change: Approved Denied
Part-time student Full-time student

Effective Term: ____________________________

X_______________________________________
Signature of Registrar’s Designee Date