Affidavit (Or Affirmation) And Application For Certificate Of Residence Form printable pdf download

AFFIDAVIT (OR AFFIRMATION) AND APPLICATION FOR CERTIFICATE OF RESIDENCE

Pursuant to §6301 & §6305 of the Education Law

** PRINT ALL INFORMATION **

: ______ - ____ - ________

Social Security No

Student Must Complete All Shaded Areas

( ______ ) ______ - __________

Telephone No:

STATE OF NEW YORK, COUNTY OF

For the Semester Beginning 20_______

________________________________

Fall

Winter

Spring

Summer

(Home County)

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

(Print Full Name)

___________________________________________, in the (City) (Village) (Town) of ___________________,

(Print Permanent Legal Address)

County of _________________________, State of New York (Zip Code: ___________); that I now am and

have for a period of one year prior to the date of this affidavit (or affirmation) been a resident of the State

of New York; and that I now am, or have been for a period of six months prior to the date of this affidavit

(or affirmation) a resident of the County of _________________________, and that I have resided at this

address from ______________ to _Present_.

Month/Year

Property Owner’s Name: ____________________________________________________________________

If less than one year at the above address, list your addresses for the PAST YEAR:

_____________________________________________________ _________________to

____________________

(Print Legal Address)

Month/Year

_____________________________________________________ _________________to

____________________

(Print Legal Address)

Month/Year

Citizenship:

United States

Other: ______________ Visa Type _____ Resident Alien #_____________

Country

I further state I plan to enroll in Genesee 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

(Home County)

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

YOUR SIGNATURE MUST BE NOTARIZED IF YOU LIVE

______________________________________________

OUTSIDE GENESEE COUNTY.

(YOUR SIGNATURE)

(DATE)

Sworn to before me this _______________ day

THIS SPACE FOR USE OF

of ____________________________ 20 _______

CHIEF FISCAL OFFICER OF COUNTY

____________________________________________

___________________________________________________

(Notary Public or Commissioner of Deeds)

(SIGNATURE)

(DATE)

Education Law, §6305, provides: “The chief fiscal officer of each county, as defined §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 certificate of residence shall be valid for a period

of one year from the date of issuance.” Education Law, §6301, ¶5, defines: “Resident” as a person who has resided in the state for a period of at least one year and in the county for 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 §6305 of this article, his or her 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

application for a certificate of residence pursuant to §6305 of this chapter, the charges to the counties of residence shall be allocated among several counties proportional to the number of

months, or major fraction thereof, of residence in each county.

Affidavit (Or Affirmation) And Application For Certificate Of Residence Form

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