Certificate of Residence for New York City Residents

PLEASE PRINT ALL INFORMATION SEE REVERSE SIDE FOR DIRECTIONS

LAST NAME FIRST NAME

SOCIAL SECURITY # - - COMMUNITY COLLEGE

Important: A Certificate of Residence must be dated two (2) months or less prior to the start of the semester.

CERTIFICATE OF RESIDENCE

AFFIDAVIT (or AFFIRMATION) and APPLICATION

For New York City Residents

InconnectionwithattendanceatcommunitycollegesinNewYorkState.

PursuanttoArticle126,Sections6301&6305oftheEducationLaw.

I, ______________________________________________ ____________ do hereby swear (or affirm) that I reside at

(applicant's full name)

__________________________________________________________________, State of New York; that I now am

(permanent New York City address, including borough and zip code)

and have for a period of at least one year immediately prior to the date of this affidavit (or affirmation) been a resident

of the State of New York; that I now am, and have be en for at least six months immediately prior to the date of this

affidavit (or affirmation), a resident of New York City, county of ____ _________________, and that I have lived at the

(county of residence)

following places during the year immediately prior to the date of this affidavit (or affirmation) and application:

ADDRESS(ES) DATES (From – To)

I further state that I plan to enroll in _____________________________________ ___________ and that this affidavit

(community college)

(or affirmation) is made for the purpose of securing from the Chief Fiscal Officer of the City of New York a certificate of

residence pursuant to the requirements of Article 126 of the Education Law.

___________________________________________________

(sign in presence of Notary Public or Commissioner of Deeds)

Your signature must be notarized before this affidavit (or affirmation) is submitted.

Swornto(oraffirmed)beforemethis

__________dayof________________________________,20________

NotaryPublicorCommissionerofDeeds

EducationLaw,Section6305(3),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non‐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not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."

Rev. 7/12

THIS SPACE FOR USE OF CHIEF FISCAL OFFICER OF NEW YORK CITY (COMPT ROLLER)

Certificate issued ( ) Certificate not issued ( )

Date _____________________ By _______________ _________

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