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Metropolitan Community College
Blue River • Business & Technology • Longview • Maple Woods • Penn Valley
Residency Affidavit
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Please return this form and all supporting documentation (see list of items below) prior to the start of classes.
Submitting evidence after the start of a semester will result in changes being applied to the next upcoming semester.
Documents may be submitted in the following ways:
In person to any MCC records office
By mail to : Student Data Center, Metropolitan Community College
3200 Broadway, Kansas City, Missouri 64111
By fax to: Student Data Center, 816/759-1149
By email to:
[email protected] Name_________________________________________________ Current Age____________
Student ID Number______________________ Phone _________________________________
Home Address __________________________________________ City ___________________
State _________ Zip _____________County (example: Clay, Jackson) ____________________
Public School District for Home Address ____________________________________________
I physically took residence at the above current address__________________________________
(mm/dd/yyyy)
Provide the following items that attest to your residency for the past 12 months. Please submit as many items as
possible. This list is not exhaustive and serves only to provide examples of items that will be considered for your
case. For more information visit www.mcckc.edu/tuition.
Valid Driver’s License or State ID
~and~
Most recent Personal Property Tax statement (available through your local county assessor’s office).
Proof from assessor’s office which includes the above home address and the public school district
Missouri vehicle registration
Other proof of physical residence (lease/rental agreement or mortgage statement)
NOTE:
If you are under 21 years of age and are not legally emancipated please provide proof as it pertains to
your legal guardian. You must also provide proof showing you are a dependent of the person listed.
I hereby certify that to the best of my knowledge the preceding information is true. I understand
that deliberate falsification and/or omissions of information pertaining to this affidavit may result in disciplinary
action.
Student’s Signature: ______________________________________________ Date:________________
Office Use Only: Reviewed by: __________________________________ Date: __________
Proof Acceptable � yes � no Notes: ______________________________________________
____________________________________________________________________________
Residency determined: � in-district � out-of-district � out-of-state
12/16 Public School District: _________________________________________________________
