STATE of NEW YORK, COUNTY OF SARATOGA
AFFIDAVIT AND APPLICATION FOR CERTIFICATE OF RESIDENCE
IN CONNECTION WITH ATTENDANCE AT A COMMUNITY COLLEGE
I, ________________________________________________________________________, hereby swear (or affirm) that I reside* at:
Name
______________________________________________________________________________________________________________________________________.
Physical Street Address City State, Zip
I have lived at the above address from _____ / _____ / _____ to present.
My current physical address is located in the Town of _________________________, in the County of___________________, State
of New York. I swear (or affirm) that I have been a resident* of the State of New York for a period of at least one year immediately
prior to the date of this affidavit and application, and that I have been a resident* of the County of Saratoga for ___
of the six months
immediately prior to the date of this affidavit, and that I have resided at the following places during the year immediately prior to the
date of this application (knowingly providing false information is a crime punishable by law):
Former addresses include:
__________________________________________________________________ _____ / _____ / _____ to _____ / _____ / _____
__________________________________________________________________ _____ / _____ / _____ to _____ / _____ / _____
I further swear (or affirm) the following information:
Date of Birth_____ / _____ / _____ US Citizen Y N Place of Birth USA [ ] Other [ ]:(specify) ____________________
Date of high school graduation / GED (or anticipated date) ___/___ [ ] Active Duty Military
Social Security No. ___ ___ ___ -- ___ ___ -- ___ ___ ___ ___
[ ] Spouse or Dependent of Active Duty Military
Phone # (Day) ________________________ Mailing Address if different ______________________________________________
I further state that I am registered / expect to be registered at ____________________________________________ Community
College and will attend the college during the ____________________ /_________ semester.
(Term) (Year)
Current High School Student? Y N If yes, _______________________________________________/_______
High School Name Grade
_________________________________________________________
SIGNATURE OF APPLICANT / DATE
Certificate [ ] issued [ ] rejected by: _______________________________________________on ________ / ________ / _________
*”Resident” is defined by New York Education Law, Section 6301, paragraph 4, and Saratoga County Policy on Reimbursement of Community College Costs, Section III.
RESIDENCY PROOF SHOWN:
RENEWAL [ ] ______________ / ______
(Term) (Year)
________________________________________________
________________________________________________
________________________________________________
________________________________________________
FOR NOTARY PUBLIC / CLERK USE ONLY:
Sworn before me this ______ day of _________________, _______
_______________________________________________________
Notary Public
My term expires _____ / _____ / _____
Additional proof needed:____________________________________________________________________________________
Date:______________
Rev. 06/2017
Requirements
Andrew B. Jarosh, Saratoga County Treasurer
40 McMaster Street, Ballston Spa, New York 12020
Telephone (518) 884-4724 Fax (518) 884-4775
Certificate of Residency
*Refer to Education Law, Section 6301 paragraph 4, and Section 6305.
In order to have Saratoga County participate in the cost of his or her community college education, a student must obtain a Certificate
of Residency and submit it to the college. Military personnel on active duty, as well as their spouses and dependents, are entitled to
the lower “Resident” rate.
A student must apply for a certificate no sooner than 60 days prior to the start of classes and no later than 30 days after the college’s
first day of classes. Certificates remain valid for one year of semesters, provided the student attends during the semester the certificate
is issued. A student that does not register for the semester the certificate was issued, must apply for and receive a new certificate.
Students can obtain a certificate in person at the County Treasurer’s Office. Students, who are U.S. citizens residing at their current
address for at least twelve consecutive months, without moving, may obtain a certificate from their town or city clerk prior to the cut-
off date. Cut-off dates are dictated by the start of classes at each college and will vary. Town and city clerks are only authorized to
issue certificates until the start of the college semester. Students applying for a certificate after the beginning of the college semester
must apply at County Treasurers office. An application will be accepted from an individual other than the student only if the
student’s signature on the affidavit has been notarized and sufficient proof is submitted.
Eligibility
A student must be a continuous resident of New York State for one year immediately preceding the date of application
AND
A student must have been a resident of Saratoga County for at least one month within the six months immediately preceding
the date of application. A student that has not been a resident of Saratoga County for that entire six-month period must
obtain a certificate from each county of residence within the six-month period. He/she must apply at the County Treasurer’s
Office.
Non-citizens are required to document their resident status and must apply at the County Treasurer’s Office for their first
certificate. Non-citizens renewing a certificate of residency that have resided at their current residence for twelve consecutive
months, without moving may obtain their certificate from their town or city clerk providing the proof used for residence status
has not expired.
Elements of Acceptable Proof
At a minimum, two proofs are required: One must be 12-18 months old and one less than 30 days old.
Each document must be dated and include name and physical street address. Documents with a post office box will not
suffice unless a physical address is also indicated.
Each residence on the application must be documented. Proof will be required within 30 days of the date of any move in the
past year.
No claim of residency will be accepted solely on your testimony or that of your parents, relatives, friends or other individuals.
The standard of proof will not be compromised because you have left yourself insufficient time to obtain acceptable proof.
Examples of Acceptable Proof (must include name, physical address and be dated accordingly)
College correspondence including bills or schedule of classes
Bank statements
Utility bills
Medical records including prescriptions
Report cards with an issue date of 1year old, or within 30 days
Dated mail or postmarked envelopes
Income tax return with preprinted label or W2’s
Formal lease
Driver’s license, car registration and insurance card may be used when the issue date reflected is 1 year old, or within 30 days
of application.
Students who are not citizens of the United States applying for their first certificate must apply in the County
Treasurer’s Office
Required documentation:
Permanent Resident Card
Visa
Immigration papers indicating permanent resident status
Acceptable proof is not limited to the above examples, but proof must contain all required elements to be accepted.
Rev. 6/2017
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