REQUEST FOR CERTIFICATION

OF

SOUTH CAROLINA RESIDENCY

The Academic Common Market is a cooperative tuition-reduction agreement among the Southern Regional Education Board states. If public institutions in South Carolina do not offer degree programs in your field of study, it may be possible to arrange a waiver of out-of-state tuition to attend a cooperating public institution of higher education in another participating state.

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General Instructions

1) This form must be submitted for residency certification once the student has been accepted to the

specific degree program.

2) A copy of the Student’s Letter of Admission to the particular Program (the major must be stated)

must be sent along with this completed Request.

3) Annual re-certification is not required as long as the student's enrollment is continuous.

4) Each appropriate item must be completed before a student's eligibility for out-of-state tuition aid

can be determined.

5) Particular attention should be paid to the student's residency during the past two years. A cover

letter may be added if the student desires to give further information regarding his/her residency

status.

6) This completed and notarized form and a copy of the student's Letter of Admission (to the particular program) should be returned to:

___________________________________________________________________________________

South Carolina Commission on Higher Education

ACM Programs

1333 Main Street, Suite 200

Columbia, SC 29201

803 737-2245

1) Applicant's Name___________________________________________________________________

(Last) (First) (M)

2) Social Security Number______________________________________________________________

3) Institution you will be attending during period for which out-of-state assistance is requested

________________________________________________________________________________

4) Exact Title of Program______________________________________________________________

5) Degree Title of Program_____________________________________________________________

6) School Address (if known)___________________________________________________________

7) Permanent Home Address____________________________________________________________

(Street)

__________________________________________________Telephone__________________________________

(City) (State) (Zip)

8) Place of Birth___________________________________ Date of Birth_______________________

(City) (State) (Zip)

9) Were you claimed as a dependent by your Parent(s), Guardian(s), or Spouse on their most recent

Federal income tax return?______Yes _____No If No, Please Skip to Question #13.

10) Name (s) of Parent(s)/Guardian(s)/or Spouse____________________________________________

11) Address of Person(s) listed #10______________________________________________________

(Street or Box)

___________________________________________________Telephone____________________________

(City) (State) (Zip)

12) Have Parent(s)/Guardian(s)/or Spouse lived at the above address for all of the past two years?

_____Yes _____No If No, Please Give Previous Address and Date of Move

______________________________________________________________________________

(Street) (City) (State) (Zip) (Date of Move)

13) Has address in #7 become your address during the past two years? _____Yes _____No

If Yes, please give previous address and date of move to present address

______________________________________________________________________________

14) Where did you graduate from (or last attend) high school? Date graduated ___________________

_____________________________________________________________________________

(Name of School) (City) (State) (Zip)

15) Institution(s) attended after high school Residency

______________________________________ From____To______ Degree____Status_______

Institution/City/State

Residency

______________________________________From____ To______Degree____ Status_______

Institution/City/State

16) Are you registered to vote______Yes______No If yes, in what state_____________________

17) Are you licensed to drive______Yes______No If yes, state license issued________________

18) Is any motor vehicle registered in your name_____Yes____No If yes, state registered___________

19) Have you ever served on a jury______Yes_____No If yes, in what state___________

20) Have you ever been gainfully employed in South Carolina______Yes ______No

If yes, please provide information below for your three (3) most recent jobs

Employer City Position From (Mo/Yr) To (Mo/Yr) P/T or F/T

21) If you answered yes to item #9, provide employment information for those individuals on whom you
are financially dependent (parents/guardians/spouse).

From To PT

Employer City Position (Mo/Yr) (Mo/Yr) or F/T

22) Are you a United States citizen ____Yes____No If no, what is your VISA classification _________

I hereby swear (or affirm) that all entries on this form are accurate.

_________________________________________________________

Signature (in presence of notary)

Sworn to (or affirmed) before me this____________day of _______________,20_______

Signature_________________________________________________________

Notary Public

My Commission Expires____________________________________________

7/26/2001