Affidavit And Application For Certificate Of Residence In Connection With Attendance At A Community College Form - New York

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STATE of NEW YORK, COUNTY OF SARATOGA

AFFIDAVIT AND APPLICATION FOR CERTIFICATE OF RESIDENCE

IN CONNECTION WITH ATTENDANCE AT A COMMUNITY COLLEGE

I, ________________________________________________________________________, hereby swear (or affirm) that I reside* at:

Name

______________________________________________________________________________________________________________________________________.

Physical Street Address

City

State

Zip

I have lived at the above address from _____ / _____ / _____ to present.

My current physical address is located in the Town of _________________________, in the County of___________________, State

of New York. I swear that I have been a resident* of the State of New York for a period of at least one year immediately prior to

the date of this affidavit and application, and that I have been a resident* of the County of Saratoga for ___ of the six months

immediately prior to the date of this affidavit, and that I have resided at the following places during the year immediately prior to the

date of this application:

Former addresses include:

__________________________________________________________________ _____ / _____ / _____ to _____ / _____ / _____

I further swear (or affirm) the following information:

Date of Birth _____ / _____ / _____ US Citizen

N Place of Birth USA [ ] Other [ :(specify) ___________________

Date of high school graduation / GED (or anticipated date) ___ / ___

Active Duty Military

Social Security No. ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___

[ ] Spouse or Dependent of Active Duty Military

Phone # (Day) ________________________

Mailing Address if different ______________________________________________

I further state that I am registered / expect to be registered at ____________________________________________ Community

College and will attend the college during the ____________________ /_________ semester.

(Term)

(Year)

Current High School Student? Y / N

If yes, _______________________________________________/_______

High School Name

Grade

FOR NOTARY PUBLIC / CLERK USE ONLY:

_________________________________________________________

SIGNATURE OF APPLICANT / DATE

Sworn before me this ______ day of _________________, _______

_______________________________________________________

RESIDENCY PROOF SHOWN:

Notary Public

RENEWAL [ ] ______________ / ______

My term expires _____ / _____ / _____

(Term)

(Year)

________________________________________________

Certificate [ ] issued [ ] rejected by: _______________________________________________on ________ / ________ / _________

*”Resident” is defined by New York Education Law, Section 6301, paragraph 4, and Saratoga County Policy on Reimbursement of Community College Costs, Section III.

Additional proof needed:____________________________________________________________________________________

Date:______________

Rev. 06/2013