Affidavit (or affirmation) and application for
CERTIFICATE OF RESIDENCE
Pursuant to Education Law, sections 6301* and 6305** in connection with attendance at a community college
1. Semester Certificate of Residence Application for: 2. Semester Year:
3. United States Citizen: No
(complete question 3a.) Yes – (Social Security Number):
3 a. Permanent Resident: No (complete question 3b.) Yes – (Social Security Number):
3b. Visa Type: Date of Issue: Expiration Date:
Immigrant Alien "Green Card" number: (must provide copy)
I,
(name of student), , do hereby declare that I reside at the
following address
(permanent address of student – no PO Box):
Street Address (do not list a PO Box)
City State Zip Code
in the County of Orange, State of New York; that I am now, and have for a period of at least one (1) year immediately
prior to the date of this affidavit (or affirmation) and application, been a resident of the New York State; that I am now
a resident of the County of Orange, for at least six (6) months.
If not, I declare that I have lived in New York State at the following address during the year immediately prior to the
date of this affidavit (or affirmation) and application
(previous address of student – no PO Box):
to
Street Address (do not list a PO Box) Start Date End Date
City State Zip Code Name of County
(A partial certificate can be issued if the student has lived in New York State for at least one (1) year)
Applicant further states that I plan to enroll in
(name of College or Institute) Community College
and that this affidavit (or affirmation) and application is made for the purpose of securing form the Chief Fiscal Officer
of the County of Orange a Certificate of Residence pursuant to the requirements of Article 126* of the Education
Law.
PLEASE SIGN FORM IN THE PRESENCE OF A NOTARY PUBLIC
Signature of student: Phone Number:
Email:
Notary Public's Signature:
Sworn to before me this day of , 20
* 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, issued to any person desiring to enroll in a community college as a non-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 not 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.”
Education Law, section 6301, paragraph 4, defines: “Resident.” 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 of such
person’s registration in a community college or, for the purposes of section sixty-three hundred five of this chapter, his application for a certificate of
residence.
** In the event that a person qualified as above for state residence, but has been a resident of two or more counties in the state during the six months immediately
preceding his application for a certificate of residence pursuant to section sixty-three hundred five of this chapter, the charges to the counties of residence shall
be allocated among the several counties proportional to the number of months, or major fraction thereof, of residence in each county.
SUNY B-80 05-13
