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The University of Texas at Dallas
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STATE OF TEXAS - COUNTY OF ____________________ ยง

Before me, the undersigned Notary Public, on this day personally appeared ___________________________________________________, known to me, who being by me duly sworn upon his/her oath, deposed and said: 1. My name is ________________________________________________________. I am ___ years of age. I have personal knowledge of the facts stated herein and they are all true and correct. 2. I graduated or will graduate from a Texas high school or received my GED certificate in Texas. 3. I resided in Texas for three years leading up to graduation from high school or receiving my GED certificate. 4. I have resided or will have resided in Texas for the 12 months immediately preceding the census date of the semester in which I will enroll in __________________________________________________ (college/university). 5. I have filed or will file an application to become a permanent resident of the United States as soon as I am eligible to do so. In witness whereof, this ____________day of _______________________, _________.

___________________________________ (Signature)

___________________________________ (Printed Name)

___________________________________ (Student I.D.#)

___________________________________ (Student Date of Birth)

SUBCRIBED TO AND SWORN TO BEFORE ME, on the ___________________ day of

________________________________________, ___________________________, to certify which witness my hand and official seal.

__________________________________ Notary Public in and for the State of Texas


Last Updated: July 20, 2012