Affidavit/application For Certificate Of Residence Form printable pdf download

SUNY Orange Bursar Office

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Affidavit/Application for Certificate of Residence

AFFIDAVIT (OR AFFIRMATION) AND APPLICATION FOR CERTIFICATE OF RESIDENCE, PURSUANT TO SECTION 6301 AND 6305 OF THE

EDUCATION LAW, IN CONNECTION WITH ATTENDANCE AT ORANGE COUNTY COMMUNITY COLLEGE*

Semester: Fall

Spring

STATE OF NEW YORK,

COUNTY OF _______________

Summer I

Summer II

Name____________________________________________ Student ID#: A________________________SS #___________________________

Address:

Dates of Residency

_______________________________________________________________________________ From____/____/_____ To____/____/_____

Street

City

State

Zip

County

Previous (If less than 2 years at current)

_______________________________________________________________________________ From_____/_____/_____To____/____/_____

Street

City

State

Zip

County

_______________________________________________________________________________ From_____/_____/_____To____/____/______

Mailing Address:________________________________________________________________________________________________________

(If Different Than Above)

Citizenship: U.S. Citizen

Other

Visa

Type __________

Permanent Resident Alien#_______________________________________

Date of Issue ________________________________

ATTACH A COPY OF YOUR PERMANENT RESIDENT ALIEN CARD (IF APPLICABLE)

I hereby swear (or affirm) that I reside at the above stated address; that I now am and have for a period of at least one year immediately prior to the

date of this affidavit (or affirmation) and application; been a legal resident of the State of New York; that I now am and have been for a period of at

least six (6) months** immediately prior to the date of this affidavit (or affirmation) and application, a legal resident of the County of

_______________. I further state I plan to enroll in Orange County Community College and that this affidavit (or affirmation) and application is

made for the sole purpose of securing from the Chief Fiscal Officer of the County of________________________ a certificate of residence pursuant

to the requirements of Article 126 of the Education Law.

I hereby swear (or affirm) that I reside legally at the above home address and that I have, for two years immediately prior to the date of this affidavit

(or affirmation) and application, resided as stated above.

____________________________________________ ________________________

Signature of Applicant

Date

Sworn to (or affirmed) before me this

________ day of ______________, 20________

________________________________________

Notary Public or Commissioner of Deeds

*EDUCATION LAW, SECTION 6305, PROVIDES: “THE CHIEF FISCAL OFFICER OF EACH COUNTY, AS DEFINED IN SECTION2.00 OF THE LOCAL FINANCE LAW, SHALL UPON APPLICATION AND

SUBMISSION TO HIM OF SATISFACTORY EVIDENCE, ISSUE TO ANY PERSON DESIRING TO ENROLL IN A COMMUNITY COLLEGE AS A NON-RESIDENT STUDENT, A CERTIFICATE OF

RESIDENCE SHOWING THAT SAID PERSON IS A RESIDENT OF SAID COUNTY.... SUCH PERSON SHALL, UPON HIS REGISTRATION FOR EACH COLLEGE YEAR, FILE WITH THE COLLEGE SUCH A

CERTIFICATE OF RESIDENCE ISSUED NOT EARLIER THAT TWO MONTHS PRIOR THERETO , AND SUCH CERTIFICATE OF RESIDENCE SHALL BE VALID FOR A PERIOD OF ONE YEAR FROM THE

DATE OF ISSUANCE.” EDUCATION LAW, SECTION 6301, PARAGRAPH 4, DEFINES: “RESIDENT” A PERSON WHO HAS RESIDED IN THE STATE FOR A PERIOD OF AT LEAST ONE YEAR AND IN

THE COUNTY, CITY, TOWN, INTERMEDIATE SCHOOL DISTRICT OF SCHOOL DISTRICT, AS THE CASE MAY BE, OR A PERIOD OF AT LEAST SIX MONTHS, BOTH IMMEDIATELY PRECEDING THE

DATE OF SUCH PERSON’S REGISTRATION IN A COMMUNITY COLLEGE OR , FOR THE PURPOSES OF SECTION 6305 OF THIS CHAPTER, HIS APPLICATION FOR A CERTIFICATE OF RESIDENCE.

**IN THE EVENT THAT A PERSON QUALIFIED AS ABOVE FOR STATE RESIDENCE,, BUT HAS BEEN A RESIDENT OF TWO OR MORE COUNTIES IN THE STATE DURING THE SIX MONTHS

IMMEDIATELY PRECEDING HIS/HER APPLICATION FOR A CERTIFICATE OF RESIDENCE PURSUANT TO SECTION 6305 OF THIS CHAPTER, THE CHARGES TO THE COUNTIES OF RESIDENCE

SHALL BE ALLOCATED AMONG THE SEVERAL COUNTIES PROPORTIONAL TO THE NUMBER OF MONTHS, OR MAJOR FRACTION THEREOF, OF RESIDENCE IN EACH COUNTY.

___________________________________________________________________________________________________________

THIS SPACE FOR USE OF CHIEF FISCAL OFFICER OF COUNTY

CERTIFICATE ISSUED( )

CERTIFICATE DENIED(

)

DATE___________________BY_______________________

(03/11)