Application For Certificate Of Residence Form printable pdf download

Do you need a Certificate of Residence? For all Cayuga courses except Leisure Learning or Business/ Industry Center Workforce courses * :

• If you have resided in Cayuga County for less than 6 months or live in a New York State county other than Cayuga, you must either enclose

a Certificate of Residence with your tuition payment or pay double the tuition rate.

• The Certificate is issued by the treasurer of your county, not by Cayuga Community College. You must submit the application below with

proper documentation to your county treasurer’s office, according to that office’s rules. This should be done as soon as possible – no

sooner than 60 days before the start of class and within 14 days after the class starts.

*Note: For Leisure Learning or BIC/Workforce course coded PE or SAC, a Certificate of Residence is needed for new residents and non-residents of Cayuga County.

When Do I Need to Obtain a New Certificate?

Certificates are valid for the academic year (start of Fall semester-around September 1 until the end of Summer II semester - around August

15th) as long as enrollment is continuous. If you are enrolling beginning with the Summer Semester(s), you will need a new certificate for the

following Fall Semester.

Questions: Please call the Cayuga Community College Business office at (315)294-8450

Application for Certificate of Residence

(Pursuant to Sec. 6305 of the Education Law in connection with community college attendance)

County of _____________________________________ , State of New York _______________________________________________does hereby

(applicant name)

swear/affirm that s/he resides in the city/town/village of _________________________________________________________________________

at ______________________________________________________________, County of _____________________________, State of New York;

(number and street)

that s/he now is, and has been for a period of ____________ months within the six months immediately prior to the date of this affidavit/

affirmation and application, a resident of the County of _________________ and that s/he has lived at the following places during the year

immediately prior to the date of this affidavit/affirmation and application:

Addresses

Dates

________________________________________________________________________________________________________________________

Applicant further states that s/he plans to enroll at Cayuga Community College and that this Affidavit/Application is made for the purpose of

securing from the Chief Fiscal Officer of the County a certificate that the applicant has met the residence requirements of Article 126 of the

Education Law.

Applicant’s signature ______________________________________________ Social Security Number: _________________________________

Sworn before me this ___________________________________________ day of ____________________________________ 20 ______________

Notary Public/Commissioner of Deeds Signature _______________________________________________Date____________________________

For use by the County’s Chief Fiscal Officer only:

Certificate  issued

 not issued

NOTE: DO NOT SEND THIS FORM TO THE COLLEGE. YOU MUST SUBMIT IT TO YOUR COUNTY TREASURER.

(See addresses below or contact your county treasurer’s office.)

CORTLAND COUNTY TREASURER

OSWEGO COUNTY TREASURER

TOMPKINS COUNTY TREASURER

Cortland County Courthouse

County Building

Tompkins County Courthouse

60 Central Ave., Cortland, NY 13045

46 East Bridge St., Oswego, NY 13126

125 East Court St., Ithaca, NY 14850

(607) 753-5070

(315) 349-8393

(607) 274-5545

ONONDAGA COUNTY TREASURER

SENECA COUNTY TREASURER

John H. Mulroy Civic Center

WAYNE COUNTY TREASURER

1 Dipronio Dr., Waterloo, NY 13165

421 Montgomery St., Syracuse, NY 13202

16 William St., Lyons, NY 14489

(315) 539-1735

(315) 435-2889

(315) 946-7441

ONTARIO COUNTY TREASURER

Ontario County Municipal Building

20 Ontario St., Canandaigua, NY 14425

(585) 396-4422

3-16 ktl

Application For Certificate Of Residence Form

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