Massachusetts Community Colleges in-State Tuition Eligibility Form
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Last Name:
First Name:
MI:
Street Address:
City:
State:
Zip:
SSN# or Student I.D. Number:
Date of Birth:
Are you a U.S. Citizen?:
Yes
No If not, please complete the following:
Are you a Permanent Resident?:
Yes
No
If yes, list alien registration number:
If you are not a U.S. Citizen or Permanent Resident, please state your Visa or immigration status in detail:
Please check the in-state or reduced tuition eligibility category that applies to you:
I have been a Massachusetts resident for six (6) continuous months and intend to remain here.
As proof of my intent to remain in Massachusetts, I possess at least 2 of the following documents, which I shall present to the institution upon request.
These documents* are dated within one (1) year of the start date of the academic semester for which I seek to enroll (except possibly for my high
school diploma). The institution reserves the right to make any additional inquiries regarding the applicant's status and to require submission of any
additional documentation it deems necessary.
Please check-off those documents you possess as proof of your intent to remain in Massachusetts:
Valid Driver's license
Utility bills*
Employment pay stub*
Valid Car registration
Voter registration*
State/Federal tax returns*
Mass. High School Diploma
Signed lease or rent receipt*
Military home of record*
Record of parents' residency for unemancipated person*
Other:
I am an eligible participant in the New England Board of Higher Education's Regional Student Program.
I am a member of the armed forces (or spouse or unemancipated child) on active duty in Massachusetts.
Certification of Information
I certify that this information is true and accurate. I understand that any misrepresentation, omission or incorrect information shall be cause for disciplinary
action up to dismissal, with no right of appeal or to a tuition refund.
Applicant's Signature:
Date:
Parent/Guardian Signature (
Applicant is under 18 years old
):
Date:
For Official Use Only DO NOT WRITE IN THIS BOX
I have reviewed the above information in order to determine this individual's eligibility to receive the in-state tuition rate. Based on my review I have
determined that this individual:
IS eligible for the in-state tuition rate.
IS NOT eligible for the in-state tuition rate.
I am unable to make a determination at this time. The following additional information has been requested from the
applicant:
Authorized College Personnel:
Date:
Please print clearly.
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