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Office of Residence Life University Housing Exemption Request Form

Per University policy, all full-time freshmen and sophomore students of Kentucky State University are required to live in University housing excluding the four designated exceptions (listed below). NOTE: Exceptions must be met before the first day of classes AND requested before signing a Two-Semester Residence Hall contract. Students who are currently in a residence hall contract agreement will not be granted a requested exception during the contracted period.

Please print and write legibly.

Student’s Name: ___ SID#: ___

Street Address Apt/Suite #

City State Zip Code

Primary Telephone Number KSU E-mail Address

Below, please mark an "X" in the box next to the appropriate exception.

Select One

Exception - I am a student who

Required Documents/Information

Is at least 21 years of age

Birth Certificate, valid Driver's License or government issued Photo ID

Notarized Parent/Legal Guardian Address Verification Form AND clear copy of parent/legal guardian's valid Driver's License or government issued Photo ID

Marriage License/Certificate

Military DD214

Commutes 50 miles or less from the principal residency of a parent or legal guardian

Is married

Is a veteran of at least two years of active military service

All supporting documentation must be submitted to the Office of Residence Life before the first day of classes. Forms submitted without the required documentation will be automatically denied. Any requests submitted and approved after the first day of classes will have charges assessed per the University’s Tuition and Fee Refund Schedule. Students will receive the decision notification via e-mail to their KSU e-mail address; students may submit a written appeal to the Residence Life Appeals Committee.

By signing below, I certify that accurate information is enclosed on this form and on the supporting documents. In addition, I understand submitting false information may result in disciplinary actions including but not limited to restitution from the University and/or other actions.

Student's Signature: _____ Date: _____

Date:

Rev. March 2016

For Office Use Only

Date Documentation Submitted: ___ Received by: ___

Request Decision: ___ Amount of Charges Accessed: $___

Dir. of Res. Life's Signature: ___ Date: ___

Date Decision E-mail Sent: ___

Appeal Process

Date Appeal Received: ___ Date Forwarded to Committee: ___

Committee's Meeting Date: ___ Committee's Appeal Decision: ___

Date Decision E-mail Sent: ___ Date Banner System Updated: ___

Rev. March 2016