Fillable COLLEGE CONNECTIONS CERTIFICATE OF RESIDENCE (Jamestown Community College)

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COLLEGE CONNECTIONS CERTIFICATE OF RESIDENCE (Jamestown Community College)

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BROWSE JAMESTOWN COMMUNITY COLLEGE FORMS

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COLLEGE CONNECTIONS
CERTIFICATE OF RESIDENCE
This form is for students who live in Allegany, Erie, Wyoming, or any NYS county
other than Chautauqua and Cattaraugus. New York state law requires students to file a new certificate of
residence every year. Follow the directions from your county regarding how to receive an affidavit for your certificate or
residency.
Allegany County
Erie County
Wyoming County
NOTE: If you live in Chautauqua County or Cattaraugus County, go to www.sunyjcc.edu/CCcor and fill out the online form.
Please follow directions carefully:
Please type on this form or print legibly and in blue or black ink. Do not use pencil.
Provide all information requested. Form must be signed and notarized. Do not sign the form until in the presence of a
notary.
Legal address should list street, road, or route number. RDs and PO box numbers are not sufficient.
Students must account for at least one year of residency in NYS. Accounts that do not have this form on file will be
assessed non-resident status and be billed for out-of-state tuition.
Students in Allegany and Erie counties must attach proof of residence with this form. Proof of residence must have the
student’s name and address on it, such as:
Copy of a NYS issued photo ID (ie: driver’s license or learner’s permit)
Copy of a high school transcript
NYS Fishing or hunting license
Bank statement
W-2 statement
Native American address verification
For tuition purposes, New York residency means that you have lived in this state as a permanent resident for 12 months prior to the start of
the semester. New York State Education Law 6305 requires the college to have a current certificate of residence on record for your student
account every academic year. Please complete this form no earlier than 60 days prior to the start of the semester. You can have your
signature notarized at your high school. Your county treasurer, clerk, or comptroller’s office may also offer notary services (call first for an
appointment). Many banks and post offices also have notary publics on staff.
Give your notarized form to your high school counselor or scan and email it to CollegeConnections@mail.sunyjcc.edu.
Please contact the College Connections office if you have questions at 716.338.1160. Thank you for your cooperation in completing this proof
of residency requirement.
FALL START DATE: SPRING START DATE:
September 7 February 1
College Connections
Jamestown Community College
PO Box 20
Jamestown, New York 14702-0020
716.338.1160
www.sunyjcc.edu/CollegeConnections
PLEASE FILL OUT FORM ON REVERSE SIDE COMPLETELY.
Student JNumber (if known) Social Security Number
Student’s Name:
Last First Middle Initial
Parent or Guardian:
Last First Middle Initial
Home Phone Cell Phone High School
Student’s Permanent
Legal Address: Street/Road Number Street/Road Name
City State ZIP
Township
How long have you lived at your address?
County (check one)
___________ year(s) and ___________ month(s)
Allegany Erie Wyoming
Other: ___________________________________
Street/Road Number Street/Road Name City State ZIP
Township County
Name of Property Owner: First Last How long did you live at this address?
___________ year(s) and ___________ month(s)
Street/Road Number Street/Road Name City State ZIP
Township County
Name of Property Owner: First Last How long did you live at this address?
___________ year(s) and ___________ month(s)
I hereby certify the above address is my permanent legal address, and that I have been a resident of New York state for one (1) year and
of the county named above for the last six (6) months preceding my enrollment at Jamestown Community College, Jamestown, NY.
Date: ________________ Student Signature: _______________________________________________________________________
Notarization Date: ________________ Signature of Notary Public: _______________________________________________________
* * * * * * * * * * * * * * * * * * * * * * * * * * * * * DO NOT WRITE BELOW THIS LINE * * * * * * * * * * * * * * * * * * * * * * * * * * * * *
This is to certify that _____________________________________________________ is presently residing in the City or Town (specify)
of ___________________________________________ and has resided in the State of New York for a period of at least one year and in
the County of ________________________________________________for at least six months immediately preceding the date hereof.
dated at _______________________________, New York this __________________day of ________________________________ 20________.
County Treasurer/Comptroller/Clerk Signature : ______________________________________________________________________________________________________
If you have lived at your present address for more than one year, skip to the next section of the form. If you have not lived at the addresses stated above for one year, you must
list previous address(es).
* * * ONLY SIGN THIS FORM IN THE PRESENCE OF A NOTARY PUBLIC * * *
OFFICE USE ONLY CC
County ________/________
Town ________/________
Months ________/________
Semester _________________
JNumber _________________
FALL START:
September 7
SPRING START:
February 1
Affidavit (or Affirmation) for Certificate of Residence Pursuant to Section 6305 of the Education Law in connection with
attendance at a community college. PLEASE PRINT LEGIBLY IN BLUE OR BLACK INK.
COLLEGE CONNECTIONS
CERTIFICATE OF RESIDENCE
Stamp of Notary Public:
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COLLEGE CONNECTIONS CERTIFICATE OF RESIDENCE (Jamestown Community College)

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Completed 29 January 2021

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