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Office of Residence Life Living with Parent/Legal Guardian & Address Verification Form Fall 2024 – Spring 2025

University policy: It is with the objective and commitment to being a residential institution that Kentucky State University requires every full-time freshman and sophomore to live on campus with the following exceptions:

Students who are veterans of at least two years of active military service

Students who commute from the home of parents or legal guardian

Students who are married

Students 21 years of age and older

Students who select to commute 50 miles or less from their parent(s)/legal guardian’s permanent principal residence must reside with their parent(s)/legal guardian, and may not live in any other housing location except University housing. Failure to comply with this requirement will result in the designated students being billed room and board charges for each semester they are out of compliance.

Student's Name: ___ SID#: ___

KSU E-mail Address: ___

Telephone #: _____

During the entire fall and spring semesters, I, ___,

will be living with my parent(s)/legal guardian in his/her permanent principal residence located at

(Street Address) ___ in

(City, State, Zip Code) ___.

Student's Signature: ___

As the parent/legal guardian of the student listed above, I, _____,

verify that my son or daughter will be living with me, for the entire fall and spring semesters, in my permanent principal residence at the address listed above.

Parent/Legal Guardian's Signature: ___

By signing this verification form, we understand that: 1) there is a continuing obligation to report any address changes to the University's Offices of Residence Life and the Registrar, 2) a change in status of address may require the student to live in University housing pursuant to the University's housing residency policy, 3) falsification of this affidavit and or failing to continuous meet this requirement may result in disciplinary actions and being charged a residence hall fee, and 4) a copy of the parent/legal guardian's current driver's license or government issued Photo ID must accompany the request form.

NOTARY PUBLIC USE ONLY

The signatures and information of both parties were witnessed set forth here

this _____ day of _____.

State of ___, County of ___

My Commission Expires: ___.

___

Notary Signature

Telephone Number