Paul D. Camp Community College – Domicile Determination Form

Complete this form to determine eligibility for in-state tuition pursuant to Section 23-7.4, Code of Virginia. Mark one domicile category (1–6), then complete either Section A or Section B as directed. Click Print to PDF at the bottom and email or submit the completed form to the Admissions Office.

Please contact the college admissions office if you have any questions.

Step 1 — Select Your Domicile Category

Mark the domicile category that applies to you below from choices 1–6. Choose only one category.

If you marked box 1 or 2, please complete Section A below.

If you marked box 3, 4, 5, or 6, please complete Section B below.

A. Applicant's Information B. Parent, Legal Guardian, or Spouse's Information

1. Applicant's Name

First

Middle

Last

Date of Birth:

2. Are you a U.S. Citizen? Yes No

If Yes, skip to #3.

If No, are you a permanent resident? Yes No

If Yes, what is your "A" number?

If No – What is your immigration status?

1. Provide the name of the person upon whom you are basing your domicile.

First

Middle (Full)

Last

2. Using the above person's information, answer the questions below.

Is the above person a U.S. citizen? Yes No

If Yes, skip to #3.

If No, is he/she a permanent resident? Yes No

If Yes – What is his/her "A" number?

If No – What is his/her immigration status?

3. Have you lived in Virginia for the last 12 months? Yes No

If No, list address(es) for the last 24 months:

From Date To Date

Address

From Date To Date

Address

3. Has the above person lived in Virginia for the last 12 months? Yes No

If No, list address(es) for the last 24 months:

From Date To Date

Address

From Date To Date

Address

5. For the past twelve months, have you lived out-of-state, worked in Virginia, and paid Virginia income taxes on at least $14,500 of earned income? Yes No

If Yes, list state:

5. For the past twelve months, has the above person lived out-of-state, worked in Virginia, and paid Virginia income taxes on at least $14,500 of earned income? Yes No

If Yes, list state:

If you knowingly provide erroneous information to evade payment of out-of-state tuition and fees, you will be charged out-of-state tuition and fees for each term attended and may be subject to dismissal. Random audits of this information will be performed. I certify under penalty of disciplinary action that all of the information is complete and accurate. I agree to supply the college with supporting documentation related to my application if I am requested to do so.

Signatures

Signature of Applicant Date

Signature of Parent, Legal Guardian, or Spouse Date

Revised 5/20/21