80 Vandenburgh Avenue // Troy, New York 12180-6096
College in the High School
Certificate of Residence for Rensselaer County
Last four digits of SSN: XXX - XX - _______
Last Name ____________________________________ First Name ___________________________ M.I. _______
(Please Print)
Current Street Address _____________________________________________________________
(no P.O. boxes allowed)
_____________________________________________________________
Physical City/Township in which you live: ( 49 / __________ )
How long have you lived at the address listed above? ________________________
Certification Statement
: I do hereby certify that I am now, and have been for a period of at least one year
immediately prior to the date of such application, a resident of the State of New York: and now am, or have
been for a period of ________ months within the 6 months immediately prior to the date of such application,
a resident of the County of Rensselaer.
I understand that I will incur an additional NON-RESIDENT tuition liability if my Town/City Clerk denies this Certificate
of Residence.
_______________________________________________ __________________
Student Signature Date
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Berlin ( 73 )
Brunswick ( 74 )
E. Greenbush ( 76 )
Grafton ( 77 )
Hoosick ( 78 )
Petersburg ( 79 )
Nassau ( 80 )
N. Greenbush ( 81 )
Pittstown ( 82 )
Poestenkill ( 83 )
City of Rensselaer ( 84 )
Sand Lake ( 85 )
Schaghticoke ( 86 )
Schodack ( 87 )
Stephentown ( 88 )
Troy ( 89 )
