H________________________
Admissions & Records Office
California Residence Questionnaire
All students requesting residency reclassification must complete this form and supply all necessary dates, and provide required
support documentation.
1 of 3
September 2020
Office use only: Initials: ______
Semester/Year: ____________
Residence code: ____________
Identification Information: (Please print using blue or black ink)
Name: (Print full legal name. DO NOT use nicknames, initials or abbreviations)
_______________________________________ ____________________________________ _________
Last First Middle
Student’s Permanent Address:
__________________________________________ _____________________________ ___________________
Street City State and Zip Code
_______________________________________ _________________________________ _____
AHC Student ID Number Date of Birth Age
Phone number: ________________________________________
Residence Requirements: (Title 5, 54020 and 54028) Establishing residence requires both physical presence in
California and objective evidence that there is the intent to make California your home for other than a temporary
purpose. The one-year-and-a-day residence period does not begin until you are present in California AND have
demonstrated clear intent to become a California resident. If you are not a United States citizen or on a visa that allows you
to establish California residency, you must provide verification that you have applied for residency with the Bureau of Citizenship
and Immigration Services.
Having read the above, I consider myself a California resident for tuition purposes. Yes No
Physical Presence: (Title 5, 54022) You must have been continuously physically present in California for one year and a
day prior to the first day of the term in which you wish to be declared a resident for tuition purposes.
I arrived in California on (enter date): ___________________________ (mm/dd/yyyy)
I have been away from California since the above date for longer than a temporary purpose: Yes No
I am in California only for educational purposes: Yes No
Be prepared to provide primary and supplemental proof of residency as defined on AHC’s public website.
Please continue to page 2 of the California Residence Questionnaire