APPLICATION FOR CERTIFICATE OF RESIDENCE
PURSUANT TO SECTIONS 6301 AND 6305 OF THE EDUCATION LAW
SEMESTER FALL _____ WINTER _____ SPRING _____ SUMMER _____
Social Security No. _________________________
I, _________________________________________ do hereby swear (or affirm) that I reside
at __________________________________________, in the Town of _______________________,
Zip Code ______________ County of _____________, State of New York.
Have you been a legal resident of New York State for AT LEAST ONE YEAR immediately prior
to the date of this affidavit? Yes ______ No ______
Have you been a resident of Essex County for AT LEASE SIX MONTHS immediately prior to
The date of this affidavit? Yes ______ No ______
If you have lived less than one year in New York State or less than six months in Essex County,
list your addresses for the past year below – do not include previous school address.
Address From (m/d/y) To (m/d/y)
I FURTHER STATE THAT I PLAN TO ENROLL IN:
(Name of College)
and that this affidavit and application is made for the sole purpose of securing from the Chief Fiscal
Officer of the County of Essex, a certificate of residence pursuant to the requirements of Article 126 of
the Education Law.
Signature of Applicant Date
Sworn to (or affirmed) before me this
______ day of ______________________ 20___
Notary Public or Commissioner of Deeds
Certificate issued _____ Certificate not issued _____ Date_______________ By ______________