Affidavit And Application For Certificate Of Residency Form

AFFIDAVIT AND APPLICATION FOR CERTIFICATE OF RESIDENCY

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

STATE OF NEW YORK, COUNTY OF

Social Security No.___________________

Semester______________Year__________

(Home County)

I, ____________________________________________________________________do hereby swear (or affirm)

(Full Name)

that I reside at ____________________________________________________________________, in the (City)

(Local Address)

(Village) Town of ________________________, County of _____________________, State of New York; that I now

am, or have been for a period of one year 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___________________________________.

Permanent Address:__________________________________________________________________________

LIST ADDRESS FOR THE PAST FOUR (4) YEARS

Address

Date (From – To)

_________________________________________________________

__________________________________

_________________________________________________________

__________________________________

_________________________________________________________

__________________________________

Home Phone Number _________________________

Name Listed Under_________________________________

Citizenship: United States Citizen

Other

Visa Type _________ Resident Alien#______________________

I further state I plan to enroll in ____________ and that this affidavit (or affirmation) and application is made for the

(College)

sole purpose of securing from the Chief Fiscal Office of the County of ________________________ a certificate of

(Home County)

Residence pursuant to the requirements of Article 126 of the Education Law.

Sworn before me this ___________day of

(Your Signature)

(Date)

______________________________________20_______.

THIS SPACE FOR USE OF CHIEF FISCAL OFFICE OF COUNTY

Certificate issued________Date____________________

(Notary Public, State of New York)

Certificate not issued_____________________________

*Education Law, Section 6301 paragraph 4, defines: “Resident” as a person who has resided in the state for a period of at least one year and 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 or such 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 of residence.

**Education Law, Section 6305, provides, “The chief fiscal officer of each county, as defined in section 2.00 of the local finance law shall, upon

application and submission to him of satisfactory evidence, issue to any person desiring to enroll in a community college as a 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 no 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.”

12/02

Affidavit And Application For Certificate Of Residency Form - Wayne County Page 3

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