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

* * P R I N T A L L I N F O R M AT I O N I N I N K * *

Social Security No. _______________________________

Important: Student Must Complete All Shaded Areas

FAXED COPIES NOT ACCEPTABLE

Semester_____________________ Year ____________

AFFIDAVIT (OR AFFIRMATION) AND APPLICATION FOR CERTIFICATE OF RESIDENCE

Pursuant to Sections 6305* & 6301** of the Education Law

STATE OF NEW YORK, COUNTY OF

Residence Phone Number (

)______________________

_________________________________________

Alternate Phone Number (

)______________________

(Legal County of Residence)

* * P R I N T A L L I N F O R M AT I O N * *

PERMANENT/LEGAL ADDRESS

__________________________________,

I, ___________________________________do hereby swear that I reside at

(Print Full Name)

(Print Legal Address)

_____________________________

____________

_____________,

in the (City) (Village) (Town) of

Zip Code

County of

State of New York; 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; 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 lived at the following places during the year

immediately prior to the date of this affidavit (or affirmation) and application:

Time frame living at above address:

______/______ to

Present Time

If less than one year, list prior addresses below:

Addresses, City, State, Zip Code

From

(please indicate time frame)

Month and Year

Citizenship: K United States Citizen K Visa Type _________________________ K Resident Alien No._______________________

I further state I plan to enroll in Niagara County 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 Certificate of Residence

(Home County)

f Article 119 and 126 of the Education Law.

pursuant to the requirements o

STUDENT SIGNATURE MUST BE NOTARIZED

Sworn to before me this ________day

____________________________________

of ______________________20____

(Student Signature)

(Date)

(Notary Public or Commissioner of Deeds)

THIS SPACE FOR USE OF

CHIEF FISCAL OFFICER OF COUNTY

____________________________________

Notary Signature

______________________________________

(Chief Fiscal Officer Signature)

(Date)

* Education Law, Section 6305, provides: “The chief fiscal office of each county, as defined Section 2.00 of the local finance law, shall upon application and

submission to him a 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, Section 6301, paragraph 4, defines: “Resident” A person who has resided in the state for a period of at least one year in the county, city,

town, intermediate school district or school district as the case may be for a period of at least six months , both immediately preceding the date of such a person’s

registration in a community college, or for the purpose of section sixty three hundred five of this chapter, his application for a certificate or 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 immedi-

ately preceding his/her application for a certificate of residence pursuant to section sixty-three hundred five of the 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.