(Street) (City) (State) (Zip)
(Last) (First) (Middle)
(Street) (City) (State) (Zip)
Semester Applying For*: Are you applying due Academic Level:
to a TAP residency review? Undergraduate
_____________________________________ Yes No Graduate/Professional
Student Name:
_______________________________________________________________________________________
Student ID: Date of Birth: Age:
_________________________ _________________________________ _______________
Email Address: Citizenship: If Other, Visa Type: (Attach Copy)
_____________________________________ U.S Other ___________________________
If you are a US permanent resident Are you an undocumented alien?
list your Alien Registration Number: ___________________ Yes No (If yes, attach expired visa)
Legal Address:
_______________________________________________________________________________________
County: Phone Number: Length of Time at This Address:
___________________________ __________________________ __________Yrs_________Mos
If less than three years, list previous address(es) below:
From
(MM/YY)
To
(MM/YY)
Address City State
Local Address: (If different from above)
_______________________________________________________________________________________
SECTION A (To Be Completed By All Applicants)
Student Accounts • SUNY Plattsburgh • 101 Broad Street • Plattsburgh, NY 12901-2681
Tel: (518) 564-3120 • Fax: (518) 564-3116 • email: myaccount@plattsburgh.edu
Application For New York State Residency For Tuition Billing Purposes
All applicants must complete Section A and either Section B or C. Enclose the required documents as requested
in the application. Please include a cover letter explaining any extraordinary circumstances or missing
documentation.
For more information: https://www.plattsburgh.edu/cost-aid/tuition/tuition-policy.html
The due date is the fourth Friday of every semester.
1. Did you attend an approved New York State high school for at least 2 years and
graduate from an approved New York State high school or have you
received a New York State General Equivalency Diploma (GED)?
Yes No
(If no, skip to line 3)
2. If yes,
Year of Completion: Name of School: City: County:
__________________ _______________________ ______________ _______________
(Attach copy of final transcript or diploma.)
3. Are you, your parent, or spouse a veteran or active duty member of the U.S.
Armed Forces? Yes No
(If yes, please submit a copy of the Home of Record, Military Orders or DD form 214.)
4. Do you have a driver’s license or State ID? Yes No If yes, from what state? __________
(Attach License Copy)
5. Do you own a vehicle? Yes No If yes, in what state is your vehicle registered? _________
(Attach Registration Copy)
6. Will you be registering a car on campus? Yes No If yes, state registered? _________
(Attach Registration Copy)
Plate Number: _______________ Owner: ____________________
7. Are you a registered voter? Yes No If yes, in what state? _________
(Attach Copy of Voter Registration)
8. In what State(s) did you (or your spouse) file resident taxes last year? ______________________
(Attach Copy of most recent signed Federal and State Income Tax Returns)
Where will you file for the current year? ______________________
9. What is your marital status? _______________________
Individuals under the age of 24 are generally not eligible for independent status. Students must provide
evidence of one full year of independent living in order to be considered emancipated.
1. Were you, or will you, be claimed as a dependent on your parents’ federal and state income tax
returns for the prior and current year?
(Current Year) 20 ___ Yes No (Prior Year) 20 ___ Yes No
2. Did you, or will you, live in an apartment, house, or other residence owned by your parents for more
than six (6) weeks during the last two years?
20 ___ Yes No 20 ___ Yes No
SECTION A (Continued)
SECTION B:
To be completed by the student. Note: If you are financially dependent on your parents they must complete
Section C of the application.
3. Do you rent or own a residence? Rent Own (Attach copy of signed lease, deed, or tax bill.)
4. Amount of financial support provided to you by parents/guardian during the prior and current year:
(Current Year) 20 ___ $ _____________ (Prior Year) 20 ___ $ _____________
5. Are you an emancipated minor, or an adult student who is financially independent from parental
support?
Yes No If Yes, when did you become independent? ______ / ______
Month Year
6. List below your sources of financial income for the past two (2) years:
From
(MM/YY)
To
(MM/YY)
Name and Address of Employer
Hours Per
Week
If not employed, please list your financial resources (e.g. unemployment, student loans, etc.):
_________________________________________________________________________________
_________________________________________________________________________________
STATE OF NEW YORK )
COUNTY OF ) SS.:
I, _______________________________________, the applicant herein, being duly sworn, do hereby affirm
that all information provided on this form and any attachments thereto, is accurate, complete and true to
the best of my knowledge. I understand that knowingly providing false information or if I withhold relevant
information in order to obtain the resident tuition rate, the University may revoke its determination of
eligibility for the resident tuition rate and that I will owe non-resident tuition to the University for each
semester or session that I have attended under these circumstances. I also may be subject to disciplinary
action.
_______________________________________________
Applicant Signature
Sworn to before me this _____________ Day of ____________________, 20 _______
_____________________________________________
Notary Public
SECTION B (Continued)
STOP! Applicant Affirmation – To Be Completed Before a Notary Public
(City)
(State)
(Zip)
(City)
(State)
(Zip)
Name: Relationship:
_________________________________________________ _________________________________
Legal Address:
_______________________________________________________________________________________
County: Phone Number: Length of Time at This Address:
___________________________ __________________________ __________Yrs_________Mos
Previous Address:
_______________________________________________________________________________________
Do you rent or own your residence? Citizenship: If Other, Visa Type: (Attach Copy)
Rent Own U.S Other ___________________________
(Attach copy of signed lease, deed, or tax bill.)
1. Do you have a driver’s license or State ID? Yes No If yes, from what state? __________
(Attach License Copy)
2. Do you own a vehicle? Yes No If yes, in what state is your vehicle registered? ________
(Attach Registration Copy)
Please list states in which you filed, or will file, resident income tax returns during the last two years; and the
current year:
(Attach copies of your most recent Federal and State income tax returns.)
20____ ___________________ 20____ ___________________ 20____ ___________________
Year State Year State Year State
I hereby certify that the above applicant is applying with my knowledge for residency status at Stony Brook
University.
STATE OF NEW YORK )
COUNTY OF ) SS.:
I, _______________________________________, being duly sworn, do hereby affirm that all information
provided on this form and any attachments thereto, is accurate, complete and true to the best of my
knowledge.
_______________________________________________
Parent Signature
Sworn to before me this _____________ Day of ____________________, 20 _______
________________________________________________
Notary Public
SECTION C:
To be completed by the parent or the custodial parent with whom the student lives, or who will claim the
student as a dependent for income tax purposes.
STOP! Parent Affirmation – To Be Completed Before a Notary Public
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