Statement of Legal Residence

CSLR-26271

For what term or quarter are you completing this Statement of Legal Residence?

Fall Quarter 2012

Do you claim to be a resident of California?

Yes

No

Are you a citizen of the United States?

Yes

No

Is your Father a citizen of the Unites States?

Yes

No

Is your Mother a citizen of the Unites States?

Yes

No

Have you been physically present in California for the past three years?

Yes

No

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Has your Father been physically present in California for the past three years?

Yes

No

Has your Mother been physically present in California for the past three years?

Yes

No

Final Submission
Review Your Answers Before Signing and Submitting Your Statement of Legal Residence

As you proceeded to complete this Statement, based on your responses, only those pages you were required to answer have been displayed to you. You may not have been required to fill out all of the pages of the Statement of Legal Residence. This was done as a courtesy, rather than having you fill out the entire form. You may check your answers and make corrections by using the navigation bar at the top of this page. You must sign the Statement of Legal Residence under penalty of perjury.

Do you authorize the University of California to release information regarding your residence file to your parents?

Yes

No

Oath and Signature: I declare under penalty of perjury under the

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I declare under penalty of perjury under the laws of the State of California that the information, statements, and any documents submitted by me in connection with the determination of my residence for tuition purposes are, and each of them is, true and correct.

PRIVACY NOTICE: All of the information requested on this Statement of Legal Residence is required (by the authority of Standing Order 110.2(a)-(d) of the Regents of the University of California) for determining whether or not you are a legal resident for tuition purposes. Your registration cannot be processed without this information. The Office of the University Registrar on campus maintains the requested information. You have the right to inspect University records containing the residence information requested on this form. In accordance with the Federal Privacy Act of 1974, you are hereby notified that disclosure of your social security number is mandatory. This recordkeeping system was established prior to January 1, 1975 pursuant to the authority of The Regents of the University of California under Article IX, Section 9 of the California Constitution. The social security number is used to verify your identity.

You must fill out this form accurately as you must sign the Statement of Legal Residence under penalty of perjury when you submit online. An additional handwritten signature may be required signed under penalty of perjury or in the presence of a notary public. You may be asked by a Residence Deputy to provide additional information upon review. This revision supercedes all earlier revisions

rev. 2012

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