Affidavit And Application For Certificate Of Residency Form - Jefferson County


Jefferson County
Jefferson County Treasurer
(315) 785-3055
County Office Building
175 Arsenal St.
Watertown, NY
Nancy Brown
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.
**Students may bring the document to the county office or, mail it to the address above. **
Application (The application must be signed in the presence of a Notary Public.)
Two forms of proof (6 months prior to class starting. The proof must be in street
address, not a PO BOX address)
Photo ID.
Acceptable proof (examples):
Utility Bill, Lease agreement, Copy of Federal or State Income Tax Return (most
recent year), bank statements
High school transcript (if you were enrolled in a high school in the county’s school
district within the past year).
NYS driver’s license that is not expired with current residing address.
If your photo ID confirms your current address, the county office will require only one of the
verification listed above.
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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