Fillable Printable University of Michigan Application Form - University Of Michigan

University of Michigan Application Form - University Of Michigan

UNIVERSITY OF MICHIGAN

Application for In-State Tuition on the Basis of Service

Applications must be received by 5 p.m. on the deadline date or a $300 late fee will be assessed. Return completed applications in person, by mail or fax to the

Residency Classification Office, Office of the Registrar, 1210 LS&A Building, 500 S. State St., Ann Arbor, MI 48109-1382, fax (734) 615-2432.

No applications will be accepted after the last day of classes of the term.

** FILING DEADLINES** Fall Term September 30 Winter Term January 31 Spring, Spring/Summer, and Summer Terms July 31

Please complete and sign this form if you seek to establish eligibility for in-state tuition under Part III (Service) of the University of Michigan’s

Guidelines for Qualifying for In-State Tuition. If it is determined that you qualify for in-state tuition under this category, you will continue to receive

in-state tuition as long as both (1) the University continues to offer this option within its Guidelines and (2) you continue to meet the requirements

listed below.

Name: ______________________________________ UMID: ______________________ Campus: Ann Arbor_____ Dearborn_____ Flint_____

Date of Birth:__________________ Application Term: (choose one) Fall Winter Spring Sp-Su Summer Application Year: _________

Street Address: ____________________________________________________City: ________________________________________________

State: __________ Zip Code: __________ Country: ______________ Email Address: ________________________________________________

I, the undersigned, am applying for in-state tuition on the basis of service. I hereby declare that one or more of the following apply to

me, and am providing a copy of appropriate supporting documentation, as set forth below:

I am serving on active duty in the U.S. Army, Navy, Air Force, Marines, Merchant Marine, National Guard, or Coast Guard.

•Supporting Documentation: Copies of current standard Military ID Card (such as CAC card) and current official

orders (such as current Orders on File)

I am a reservist in the U.S. Army, Navy, Air Force, Marines, Merchant Marine, National Guard, or Coast Guard.

•Supporting Documentation: Copies of current standard Military ID Card (such as CAC card) and current official

orders (such as current Orders on File)

I was honorably discharged or received a general discharge under honorable conditions from the U.S. Army, Navy, Air

Force, Marines, Merchant Marine, National Guard, or Coast Guard or its reserve component.

•Supporting Documentation: Copy of DD Form 214, Certificate of Release or Discharge from Active Duty

I am serving as an officer in the U.S. Public Health Service.

•Supporting Documentation: Copy of U.S. Public Health Service Defense Eligibility Enrollment Reporting System

(DEERS) ID Card or current standard Public Health Service ID card

I am the spouse or dependent child of someone living or stationed in Michigan who is serving in the U.S. Army, Navy, Air

Force, Marines, Merchant Marine, National Guard, or Coast Guard, whether on active duty or as a reservist.

•Supporting Documentation: Copies of servicemember’s/reservist’s Active Duty/Reserve Orders to Michigan and

proof of relationship (such as birth certificate, proof of adoption, marriage license, or Dependent’s DD 1173 or

1173-1 ID Card)

I am the spouse or dependent child of someone living or stationed in Michigan who is serving as an officer in the U.S. Public

Health Service.

•Supporting Documentation: Copy of U.S. Public Health Service Defense Eligibility Enrollment Reporting System

(DEERS) ID Card of Public Health Officer, proof of Michigan orders (such as employment letter from Public

Health supervisor stating state of employment or applicable orders) and proof of relationship (such as birth

certificate, proof of adoption, or marriage license)

DECLARATION OF TRUE AND ACCURATE INFORMATION

I, the undersigned, declare that the information (including supporting documentation) I have provided is true and accurate. I understand that this

information will be used to determine my eligibility for in-state tuition. I further understand that if any of the above information is found to be false,

misleading, or incomplete in an attempt wrongly to obtain in-state tuition, I may be subject to severe legal and disciplinary measures, including, but

not limited to, expulsion from the University and retroactive tuition charges. I also understand that the University routinely audits applications and

may, at its discretion, request additional information and documentation to verify my declaration above and ensure compliance with the University’s

Guidelines for Qualifying for In-State Tuition.

Printed Full Name: _____________________________________________________

Signature: ____________________________________________ Date: ________________________________