Please submit this form to complete your Application for Admission if you are claiming entitlement to Virginia in-state tuition pursuant to section23-7.4,
Code of Virginia. Supporting documents and additional information may be requested. All questions must be answered.
Section A - Student Information
1) Name of applicant ________________________________________________________________________________________________________
2) Social Security Number (optional) __________________________________ 3) Date of birth
___________________________________________
4) How long have you lived in Virginia? _____ year(s) _______ month(s)
5) Where have you lived, in the sense of physical presence, during the last two years? (List current address first.)
Street address City State Zip code From To
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
6) Employment information for at least one year prior to the date for which in-state tuition rates are sought (If not employed, or if retired, please indicate.):
Street address City State Zip code From To
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Yes No
7) Do your parents/legal guardian provide 50% or more of your
financial support or claim you as a tax dependent?
8) a.) If you are married, do you wish to claim eligibility for
in-state tuition rates based on your spouse’s domicile?
b.) If Yes, does your spouse provide more than 50% of your
financial support
9) Do any of the following characteristics apply to you?
Place a check beside all that apply.
Age 24 or older as of the first day of the term in which you intend to enroll
Veteran or active duty member of the U.S. Armed Forces
Graduate or first-professional student
Ward of the court or was a ward of the court until age 18
If both parents are deceased, no adoptive or legal guardian
Legal dependents other than a spouse
10) In the last tax year did you file a state return to any state
other than Virginia? If yes, please explain: ________________
11) For at least one year immediately prior to the term in which
you are claiming in-state status, will you have filed a tax
return or paid income taxes to Virginia on all earned
income? If no, please explain: __________________________
12) Are you a registered voter in Virginia?
Date registered ______ Original ______ Re-registered ______
13) Do you hold a valid Virginia driver’s license?
Date issued _________ Original ________ Renewal ________
If no, indicate your driver’s license status:
Hold in another state _______ Not licensed ______
Yes No
14) Did you own or operate a motor vehicle registered in
Virginia during the last year?
If no, indicate registration status:
Registered in another state ____
Did NOT own or operate a motor vehicle ____
15) Are you or your spouse an active duty member of the U.S.
armed forces?
If No, continue to Question 16.
If yes, who is a member: self _____ spouse ____
and answer the following:
a.) Are Virginia income taxes paid on all military income?
If yes, as of what date? _______________________________
Where were you stationed on that date? _________________
Please submit a copy of the most recent Leave and Earnings Statement.
b.) If you are in the military, or if your spouse is, are you assigned to a
Permanent Duty Station in Virginia?
If yes, as of what date? _______________________________
Where are you stationed? _____________________________
Please submit a copy of the military orders permanently assigning
you or your spouse to this station AND a copy of the military ID card
showing your relationship to the military member.
16) Answer this question only if you live outside Virginia but work in Virginia:
Will you have lived outside Virginia, been employed in Virginia,
earned at least $15,080, and paid Virginia income taxes on
all taxable income earned in this Commonwealth, for at least
one year prior to the term in which you will enroll?
If yes, please submit verication of employment, including dates and salary,
a copy of the most recent Virginia tax return, and a year-to-date pay stub.
I certify under penalty of disciplinary action that the information I have provided is true.
_______________________________________________________
________________________________________________________________
Signature of applicant Date
Last First Middle
Application for Virginia
In-State Tuition Rates
University of Mary Washington • Ofce of Admissions • 1301 College Avenue • Fredericksburg, Virginia 22401-5300
over, please
Section B - Parent, legal guardian, or spouse
This section must be completed by the applicant’s parent, legal guardian, or spouse, who during the last tax year claimed the applicant as a dependent,
or who, for the twelve months immediately preceeding the first day of classes, provided more than half of the applicant’s financial support.
1) Name of
parent legal guardian spouse _____________________________________________________________________________
2) Citizenship
U.S. U.S. permanent resident Non-U.S. Please specify visa type _______ Exp. date ________ (Please provide copy of I-94)
3) How long have you lived in Virginia? _______ year(s) ________month(s)
4) Where have you lived, in the sense of physical presence, during the last two years? (List current address first.)
Street address City State Zip code From To
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
5) Employment information for at least one year prior to the date for which in-state tuition rates are sought (If not employed, or if retired, please indicate.):
Street address City State Zip code From To Full-time/part-time
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Yes No
6)
In the last tax year, did you file a state return to any
state other than Virginia? If yes, please explain: __________
_______________________________________________
7) Will you have claimed the applicant as a dependent
on your federal and Virginia income tax return for the
tax year prior to the term in which the applicant will
enroll? If no, please explain: _________________________
8) Will you have provided more than half of the applicant’s
financial support for at least twelve months prior to the
term in which the applicant will enroll?
If no, please explain: _______________________________
9) For at least one year immediately prior to the term in
which the applicant is claiming in-state status, will you
have filed a tax return or paid income taxes to Virginia on
all earned income? If no, please explain: _______________
10)
Are you a registered voter in Virginia?
Date registered _____ Original ________ Re-registered _____
If no, indicate your registration status:
Registered in another state ______ Not registered _______
11)
Do you hold a valid Virginia driver’s license?
Date issued _________ Original ________ Renewal ________
If no, indicate your driver’s license status:
Hold in another state _______ Not licensed ______
12)
Did you own or operate a motor vehicle registered in
Virginia during the last year?
If no, indicate your auto registration status:
Registered in another state ____
Did NOT own or operate a motor vehicle ____
Yes No
13)
Are you or your spouse an active duty member of the
U.S. armed forces?
If no, continue to Question 14.
If yes, who is a member: self ______ spouse _____
and answer the following:
a.) Are Virginia income taxes paid on all military income?
If yes, as of what date? _____________________________
Where were you stationed on that date? ______________
Please submit a copy of the most recent Leave and Earnings Statement.
b.) Are you or your active-duty spouse assigned to a
Permanent Duty Station in Virginia?
If yes, as of what date? _______________________________
Where are you stationed? ____________________________
Please submit a copy of the military orders permanently
assigning you or your spouse to this station AND a copy of the military
ID card showing the applicant’s relationship to the military member.
14)
Answer this question only if you live outside Virginia but
work in Virginia:
Will you have lived outside Virginia, been employed in Virginia,
earned at least $15,080, paid Virginia income taxes on all
taxable income earned in this Commonwealth, and claimed the
applicant as a dependent for federal and Virginia income tax
purposes for at least one year prior to the term in which the
applicant is claiming in-state status?
If yes, please submit verication of employment, including dates
and salary, a copy of the most recent Virginia tax return, and a
year-to-date pay stub.
I certify that the information I have provided is true.
_______________________________________________________
________________________________________________________________
Signature of parent/guardian Date
