Application Form For Certificate Of Residence For New York State Residents

APPLICATION FORM FOR CERTIFICATE OF RESIDENCE

FOR NEW YORK STATE RESIDENTS

Rensselaer County Residents - See Other Side

THIS IS NOT A CERTIFICATE OF RESIDENCE

Bring completed application to County Treasurer’s Office and exchange it for a valid Certificate of Residence.

Your Certificate of Residence must be issued by the county you have resided in for the previous six months. If you have moved within the

last six months, you must obtain certificates from the counties in which you resided. Certificates must total six months of residency.

Submit Your Certificate of Residence, with bill and payment, to the Hudson Valley Community College Cashier’s Office.

Social Security # ________/______/________

APPLICATION

for CERTIFICATE OF RESIDENCE

PURSUANT TO SECTION 6305 OF THE EDUCATION LAW IN CONNECTION WITH ATTENDANCE AT A COMMUNITY COLLEGE*

STATE OF NEW YORK

COUNTY OF

________________________________________ does hereby swear (or affirm) that he resides ___________________________

in the (City) (Village) (Town) of ________________________________, County of _________________________ State of New York;

that he now is, or has been for a period of __________ months within the six months immediately prior to the date of this affidavit

(or affirmation) and application** a resident of the County of __________________________ and that he/she has lived at the following

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

ADDRESSES

DATES

_________________________________________________________________________

____________________________

_________________________________________________________________________

____________________________

_________________________________________________________________________

____________________________

Applicant further states that he/she has plans to enroll in Hudson Valley Community College and that this affidavit (or affirmation)

and application is made for the 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.

_____________________________________________

Signature of Applicant

Sworn to (or affirmed) before me this

____________ day of __________________________________ 20__________

__________________________________________________________________

Notary Public or Commissioner of Deeds

This space for use of Chief Fiscal Officer of County

Certificate issued (

)

Certificate not issued (

)

Date ______________________________ By _______________________________________________________________

*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 earlier than two months prior thereto, and such cer-

tificate of residence shall be 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 or school district, as the case my be, for a period of at least six months., both immediately pre-

ceding the date of such person’s registration in a community college or, for the purposes of section sixty-three hundred five 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 applica-

tion for a certificate of residence pursuant to section sixty-three hundred five of this chapter, the charges of the counties of residences shall be allocated among the several counties pro-

portional to the number of months, or major fraction thereof, of residence in each county.