Transcript
Kansas HB-2145 Affidavit This form is used to demonstrate eligibility for the resident tuition rate available to those who satisfy the HB-2145 criteria. Applicants who have completed any three years (in grades 9-12) at an accredited Kansas high school and have graduated from an accredited Kansas high school or received a GED from the state of Kansas should complete this form and submit it along with a secondary/high school transcript and/or GED results to JCCC International and Immigrant Student Services.
State of Kansas County of: _____________________________________________
(Print) Name of the county in which you reside
JCCC ID#: _____________________________
_________________________________________, being duly sworn, deposes and says that if he/she does not currently (Print)
Last/Family/Surname
First/Given Name
have lawful immigration status, that he/she has or his/her parents have filed an application to legalize his/her status or will file such an application as soon as he/she is eligible to do so. Likewise, if ___________________________________
(Print)
Last/Family/Surname
First/Given Name
does currently have a legal nonpermanent immigration status, he/she being duly sworn, deposes and says that he/she has filed an application to begin the process toward U.S. citizenship or will file such an application as soon as he/she is eligible to do so. _________________________________________ further deposes and says that, to the best of his/her
(Print)
Last/Family/Surname
First/Given Name
knowledge, he/she is not eligible to enroll in a public postsecondary educational institution located in another state upon payment of tuition and fees required of residents of such state.
____________________________________________ Student’s Signature
Stamp or seal of notary public or government official.
The above-named individual was sworn to before me this _______________ day of ___________________________________________, 20________________.
_____________________________________________________ Notary Public Commission Expiration Date
Any individual who (1) files an affidavit which contains false information, (2) fails to file an application to legalize such person’s immigration status within one year of becoming eligible, (3) fails to begin the process for citizenship within one year of becoming eligible, or (4) fails to maintain an active application for citizenship after filing therefore shall not be deemed a resident of the state of Kansas for the purpose of tuition and fees. In addition, such individual shall be required to repay the difference between the amount of fees and tuition actually paid and the amount such person would have paid as a nonresident of the state of Kansas, plus interest for the time such individual was enrolled as a resident pursuant to this section.
5106-29 R9/13
