AFFIDAVIT AND APPLICATION FOR CERTIFICATE OF RESIDENCY
Pursuant to Sections *6301 & **6305 of the Education Law
STATE OF NEW YORK, COUNTY OF
(Home County)
Social Security No.___________________
Semester______________Year__________
I, ____________________________________________________________________do hereby swear (or affirm)
(Full Name)
that I reside at ____________________________________________________________________, in the (City)
(Local Address)
(Village) Town of ________________________, County of _____________________, State of New York; that I now
am, or have been for a period of one year to the date of this affidavit (or affirmation) been a resident of the State of
New York; that I now am, or have been for a period of six months prior to the date of this affidavit (or affirmation) a
resident of the County of___________________________________.
Permanent Address:__________________________________________________________________________
LIST ADDRESS FOR THE PAST FOUR (4) YEARS
Address Date (From – To)
_________________________________________________________ __________________________________
_________________________________________________________ __________________________________
_________________________________________________________ __________________________________
Home Phone Number _________________________ Property Owner_________________________________
Citizenship: United States Citizen Other Visa Type _________ Resident Alien#______________________
I further state I plan to enroll in TC3 and that this affidavit (or affirmation) and application is made for the
sole purpose of securing from the Chief Fiscal Office of the County of ________________________ a certificate of
(Home County)
Residence pursuant to the requirements of Article 126 of the Education Law.
(Student Signature) (Date)
Sworn before me this ___________day of
______________________________________20_______.
(Notary Public, State of New York)
THIS SPACE FOR USE OF CHIEF FISCAL OFFICE OF COUNTY
Certificate issued________Date____________________
Certificate not issued_____________________________
*Education Law, Section 6301 paragraph 4, defines: “Resident” as 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 or such person’s registration in a community college, or for the purpose of section sixty-three hundred five of this chapter, his application for
a certificate of residence.
**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, issue to any person desiring to enroll in a community college as a 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 no 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.”
12/02
TC3 ID Number_____________________
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