Statement of Residence Form

Bainbridge College
Bainbridge, GA 31717-0953

A two-year college of the
University System of Georgia

Statement of Residence

Applicant's Name:_____________________ Date of Birth:______________

Social Security Number:___________________

Check the appropriate statement:

________ I am 18 years or older. I will complete and sign this form.

________ I am under 18 years of age and a dependent. My supporting parent and legal guardian will complete and sign this form.

The following information pertains to the residency of the person who is to complete and sign this form. Answer all questions.

Current Address: ____________________ ________________ ________________ ________________
street and number city county state

Date residence began at above address: (mo/year) _____________

List all other addresses where you have lived during the past twelve months:

___________________________________ from (mo/year) ________ to (mo/year) __________

Is your current address your PERMANENT HOME ADDRESS? _____YES _____NO

If the answer if NO, give permanent home address: _____________ _____________ _____________

city county state

Are you registered to vote? _____ YES _____ NO Where? __________________ __________________

city or county state
Did you pay Georgia State Income Taxes last year? _____ YES _____ NO

Do you intend to file Georgia Income Tax for this year? _____ YES _____ NO

Are you purchasing a home in Georgia? _____ YES _____ NO

Do you claim Georgia Homestead Exemption? _____ YES _____ NO

Do you pay Georgia Personal Property Taxes? _____ YES _____ NO

Do you have a Georgia Driver's License and Georgia Tags on your car? _____ YES _____ NO

Do you have a checking account in Georgia? _____ YES _____ NO

Are you in the Military? _____ YES _____ NO

If the answer is YES, give HOME OF RECORD:
__________________ __________________

(Proof of home of record must be provided.)
city state

Are you financially dependent on a parent or spouse (or guardian if under 18) who has been a legal resident for at least twelve consecutive months immediately preceding the date of registration (also, such financial dependence must have existed for the twelve months period)? _____ YES _____ NO

If yes, a copy of your parent's/spouse's income tax return of previous year and statement from parent/spouse must be submitted.

Do you teach in the Georgia Public School System? _____ YES _____ NO
or are you a spouse or a dependent child of a full-time employee of the University System? _____ YES _____ NO

The foregoing statements of this form are true and correct. I certify that I will advise the registrar of Bainbridge College if there is a change in any of the above.

Signature: _______________________________ Date: ______________

Relationship to Student: _________ Parent __________ Legal Guardian

OFFICE USE ONLY

Resident: ________ Non-Resident: _________

Effective Date: ______________

Initials: _____________

Current Address:	____________________	________________	________________	________________
	street and number	city	county	state

If the answer if NO, give permanent home address:	_____________	_____________	_____________
	city	county	state

Are you registered to vote? _____ YES _____ NO Where?	__________________	__________________
	city or county	state