Application And Affidavit (Or Affirmation) For Certificate Of Residence - Ulster County

OFFICE USE ONLY

 NYS LICENSE

ULSTER COUNTY

APPLICATION AND AFFIDAVIT (OR AFFIRMATION)

ISSUE DATE:

FOR CERTIFICATE OF RESIDENCE

________________

APPLICATION

 RPS

)

(1

(2)

 VOTER REG

NAME: _____________________________________

DATE OF BIRTH :____________

 MAIL

PRINT LEGIBLE

(3)

 ______________

RESIDES AT: _____________________________

(4) PHONE #___________________

 ______________

_______________________ N.Y.______________

City/Town

State

Zip Code

(5)

Mailing Address: _________________________________________________________________

If Different from Residential Address

(6)

HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS?

From: _____________ to _____________

Month/Year

Month/Year

(7) TOWN IN WHICH PROPERTY TAX BILL IS PAID:____________________

(8)

PREVIOUS ADDRESSES: (If you have lived at the residential address above less than one year.)

_____________________________________________________________ From ___________ to _______________

Street

City

State

Month/Year

Month/Year

_____________________________________________________________ From ___________ to _______________

Street

City

State

Month/Year

Month/Year

(

)

(

)

9

9

CITIZENSHIP: United States Citizen:

Yes _______

No _______

10

(

)

For non-citizens: Alien Registration Receipt Card

#:___________________________ Date Card Issued: __________

AFFIDAVIT (OR AFFIRMATION)

(11)

(12)

I, _________________________________, do hereby swear (or affirm) that I reside at

____________________

(13)

(14)

In the (City)(Village)(Town) of

___________________________, County of

___________________, State of New York; that I now

am and have for a period of at least one year immediately prior to the date of this application and affidavit (or affirmation), been a resident of

(15)

the State of New York; that I now am, or have been for a period of

______________ months within the six months immediately prior to

the date of this application and affidavit (or affirmation) a resident of the County of Ulster; and that I have lived at the above-listed places

during the year immediately prior to the date of this application and affidavit (or affirmation).

(16)

I further state that I plan to enroll in

_____________________________________(College or Institute) and that this application and

affidavit (or affirmation) is made for the purpose of securing from the Chief Fiscal Officer of the County of Ulster a certificate of residence

pursuant to the requirements of Article 126 of the Education Law.

(17)

(18)

____________________________________

SEMESTER/Year: Fall ____/______ Winter Interim_____/_______

Applicant’s Signature

Spring ____/_____ Summer _______/_______

(19) Are you using your G.I. Benefits or eligible for GI Benefits: Yes_____ NO_____

Sworn to (or affirmed) before me this

Certificate Issued ( )

Certificate Not Issued ( )

___________day of ___________ 20_____

Number of Months _______________

___________________________________

Date: ________________ By _____________________

Notary Public

Education Law, Section 6305 provides, “The Chief Fiscal Officer of each county, as defined in section 2.00 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

60 days prior thereto or 30 days after the start of the semester

earlier than

, 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 this state for a period of at least one year and in the

county, city, town, intermediate school district or school district, as the case may be, for a period of at least 6 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/her application for a certificate of residence.

According to Article 126 of Education Law, Section 6301 paragraphs 5, 5(i), 5(ii) and 5(iii) 1 & 2, “In the event that a person qualified for state residence but has been

a resident of two or more counties in the state during the six months immediately preceding his application for a certificate of residence, 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.”

Document: Application and Affidavit (or Affirmation) for Certificate of Residence – 12/2014