Affidavit And Application For Certificate Of Residency Form - Wayne County


Wayne County
Wayne County Treasurer
(315) 946-7441
PO Box 8
16 Williams St
Lyons, NY
Thomas Warnick
The attached application/affidavit must be completed and presented to the above address
with the appropriate proof. The County needs this form in order to determine your eligibility
for a Certificate.
Application (must be filled out at the Town Clerk’s Office. Exception of the Town of
Lyons and Town of Newark. Students must sign their signature in front of the Notary
Driver’s license or permit
Two forms of proof (one year in NY State; 6 months in Wayne County)
Acceptable proof (examples):
High school transcript (if you were enrolled in a high school in the county’s school
district within the past year).
Mail post-marked 12 and/or 6 months prior to class starting (must be street address,
not a PO BOX address).
Certificate must be obtained within the time period of 60 days before the first day of class but
no later than 30 days after the first day of class.
The original Certificate of Residence (not this application) can be delivered to any of the three
TC3 locations: Ithaca Extension Center, Cortland Extension Center or the main campus or it
can also be mailed to:
Tompkins Cortland Community College
Room #215
170 North Street, PO 139 Dryden, NY 13053.
Note: faxes or photocopies are NOT acceptable.


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