Massachusetts Community Colleges in-State Tuition Eligibility Form Please print clearly. Last Name: _______________________________________ First Name: ______________________________________ MI: ____________ Street Address: ___________________________________________________________________________________________________________ City: _____________________________________________ State: _____________________________ Zip: _________________________ SSN# or Student I.D. Number: ___________________________________________ Are you a U.S. Citizen?: q Yes Date of Birth: __________________________________ q No If not, please complete the following: Are you a Permanent Resident?: q Yes q 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: q Valid Driver’s license q Valid Car registration q Mass. High School Diploma q Utility bills* q Voter registration* q Signed lease or rent receipt* q Other: q Employment pay stub* q State/Federal tax returns* q Military home of record* q Record of parents’ residency for unemancipated person* 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: _______________________________________________________________ Parent/Guardian Signature (Applicant is under 18 years old): __________________________________ Date: ___________________________ 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: ________________________