Revised by: TL-06/ 2015
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ALTERNATE LEASE STATEMENT
Name:____________________________ __________________ Semester:______________
Last Name Fist Name
CUNYfirst Empl ID#_____________________ Phone
№ (______) _________-___________
Current Mailing Address:
_
__________________________________________ ________ ____________________ _______ ________
Street Apt № City State Zip Code
I have lived at the above address from ________/________ to ________/__________
Month/Year Month/Year
But the lease is NOT
in my name.
_______________________________________________________________________________________
TO BE COMPLETED BY THE PERSON WHOSE NAME APPEARS ON THE LEASE/CONTRACT.
I ___________________________________certify that I reside at the address indicated above and that
Owner/Leasee's Name
_____________________________________ has resided with me from _____/_____ to _____/_____
Student's Name Month/Year Month/Year
Proof that I have resided at the above address for one year is attached (e.g.: lease, telephone bill,
utility bill, apartment or house insurance, or mortgage statement).
____
___
___
_
____
_______________________
D
ate
_____/_____/_____
Signature mm dd yyyy
NOTARIZED
_______
________________________________________________________________________________
I certify that the above information is accurate and complete. I understand that this information
may affect my residency status at the college. I understand that if I provide false information or
withhold relevant information in order to obtain resident status, The City University may revoke its
determination of in-state residency, and that I will owe non-resident tuition to the University for
each semester or session that I have attended under these circumstances. I also understand that I
may be subject to disciplinary action.
_______________________________________ Date_____/_____/_____
Signature mm dd yyyy
NOTARIZED
Office of the Registrar - Division of Student Affairs
