APPLICATION FOR CERTIFICATE OF RESIDENCE
PURSUANT TO SECTIONS 6301 AND 6305 OF THE EDUCATION LAW
(SEE INSTRUCTIONS ON FOLLOWING PAGE)
SEMESTER FALL _____ WINTER _____ SPRING _____ SUMMER _____
PLEASE PRINT CLEARLY
I, _________________________________________ do hereby swear (or affirm) that I reside
at __________________________________________, in the Town of _______________________,
Zip Code ______________ County of _____________, State of New York.
Have you been a legal resident of New York State for AT LEAST ONE YEAR immediately prior
to the date of this affidavit? Yes ______ No ______
If you have lived less than one year in New York State, you do not qualify for a Certificate of
Residence.
Have you been a resident of Essex County for AT LEASE SIX MONTHS immediately prior to
the date of this affidavit? Yes ______ No ______
If you have lived less than six months in Essex County, list your address(es) below. Use your
permanent address - not your school address.
Address From (m/d/y) - To (m/d/y)
____________________________________________ ____________________________________
____________________________________________ ____________________________________
I FURTHER STATE THAT I PLAN TO ENROLL IN:
_________________________________________________
(Name of College)
and that this affidavit and application is made for the sole purpose of securing from the Chief Fiscal
Officer of the County of Essex, a certificate of residence pursuant to the requirements of Article 126 of
the Education Law.
_______________________________________ _______________________
Signature of Applicant Date
Sworn to (or affirmed) before me this
______ day of ______________________ 20___
____________________________________________
Notary Public or Commissioner of Deeds
Certificate issued _____ Certificate not issued _____ Date_______________ By ______________
LEAST
ESSEX COUNTY
CERTIFICATE OF RESIDENCE INFORMATION SHEET
Pursuant to Sections 6301 and 6305 of the Education Law
In Connection With Attendance at Community Colleges
Certificates may only be issued up to 60 days prior to each college term and up to 30 days
after the commencement of each term. Certificates are valid for a period of one year.
When applying for a certificate of residence you must complete the application and have it
notarized. The form can be filed by mail or in person at: Essex County Treasurer, P O Box
217, Elizabethtown, NY 12932. If needed, you can print a form off of the Essex County
website – www.co.essex.ny.us. On left side under county/town links select forms.
Whether applying for a certificate of residence in person or by mail - PROPER PROOF of
residence must be submitted. The proof must verify that the student has been a New York
State resident for at least one full year and an Essex County resident for at least the past six
months.
Proof must show a street address. Post Office boxes are not
acceptable proof for the purpose
of determining residency. Some proper forms of proof may be one or more of the following:
A New York State driver’s license, permit or non-driver I.D. that was issued
over one year ago – photocopy is acceptable. Post office box not acceptable unless
it is accompanied by a street address.
Voter registration card, utility bill, bank statement, rent receipt, apartment lease,
vehicle registration or insurance card, income tax return.
immediately prior to the application date and an Essex County
resident for at least the past six months.
rent receipts, apartment lease,
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