Affidavit (Or Affirmation) And Application For Certificate Of Residence Form - Dutchess County, New York

ADVERTISEMENT

AFFIDAVIT (OR AFFIRMATION) AND 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
)
SEMESTER/YEAR_________________________
)
COUNTY OF DUTCHESS )
TELEPHONE #:
(____) _______ -___________
I, _______________________________________________ do hereby swear (or affirm) that I reside at,
____________________________________________________________________________________
_____________________________________________________Zip Code _______________________
in the (check one)
City
Town or
Village of ____________________________________,
County of Dutchess, 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 affidavit (or affirmation) and application, been a resident of 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 affidavit (or affirmation) and application**a resident of the County
of Dutchess; and that I have lived at the following places during the year immediately prior to the date of
this affidavit (or affirmation) and application:
Addresses
Dates
_________________________________________
From _____________ To ___________
_________________________________________
From _____________ To ___________
Citizenship: U.S. Citizen ______ Other _______ Visa Type ________________________________
Resident Alien #_________________________________________________________
I further state that I plan to enroll in _____________________________________________________
(College or Institute) and that this affidavit (or affirmation) and application is made for the purpose of
securing from the Chief Fiscal Officer of the County of Dutchess a Certificate of Residence pursuant to
the requirements of Article 126 of the Education Law.
_________________________________________ _____________
Signature of Applicant (Before Notary Public)
Date
Sworn to (or affirmed) before this
_____day of _________________, 200___
___________________________________
Notary Public or Commissioner of Deeds
** In the event that a person qualifies as above for state residence, but has been a resident of two or more counties
in the state during the six months preceding his 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 fraction thereof, of residence in each county.
_____________________________________________________________________________________
THIS SPACE IS FOR USE OF CHIEF FISCAL OFFICER OF COUNTY
Certificate Issued ( )
Certificate Not Issued ( )
Motor Vehicle Operator’s License No:
_____________________________________
Date:_____________ By:__________________
License Issue Date: __________
Other Proof
__________________
(if required):

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go