Document: Application and Affidavit (or Affirmation) for Certificate of Residence – 12/2014
ULSTER COUNTY
APPLICATION AND AFFIDAVIT (OR AFFIRMATION)
FOR CERTIFICATE OF RESIDENCE
APPLICATION
(1
)
NAME: _____________________________________
(2)
DATE OF BIRTH :____________
PRINT LEGIBLE
(3)
RESIDES AT: _____________________________ (4) PHONE #___________________
_______________________ N.Y.______________
City/Town State Zip Code
(5)
Mailing Address: _________________________________________________________________
If Different from Residential Address
(6)
HOW LONG HAVE YOU LIVED AT THE ABOVE ADDRESS? From: _____________ to _____________
Month/Year Month/Year
(7) TOWN IN WHICH PROPERTY TAX BILL IS PAID:____________________
(8)
PREVIOUS ADDRESSES: (If you have lived at the residential address above less than one year.)
_____________________________________________________________ From ___________ to _______________
Street City State Month/Year Month/Year
_____________________________________________________________ From ___________ to _______________
Street City State Month/Year Month/Year
CITIZENSHIP: United States Citizen:
(
9
)
Yes _______
(
9
)
No _______
For non-citizens: Alien Registration Receipt Card
(10)
#:___________________________ Date Card Issued: __________
AFFIDAVIT (OR AFFIRMATION)
(11)
I, _________________________________, do hereby swear (or affirm) that I reside at
(12)
____________________
In the (City)(Village)(Town) of
(13)
___________________________, County of
(14)
___________________, State of New York; that I now
am and have for a period of at least one year immediately prior to the date of this application and affidavit (or affirmation), been a resident of
the State of New York; that I now am, or have been for a period of
(15)
______________ months within the six months immediately prior to
the date of this application and affidavit (or affirmation) a resident of the County of Ulster; and that I have lived at the above-listed places
during the year immediately prior to the date of this application and affidavit (or affirmation).
I further state that I plan to enroll in
(16)
_____________________________________(College or Institute) and that this application and
affidavit (or affirmation) is made for the purpose of securing from the Chief Fiscal Officer of the County of Ulster a certificate of residence
pursuant to the requirements of Article 126 of the Education Law.
(17)
(18)
____________________________________ SEMESTER/Year: Fall ____/______ Winter Interim_____/_______
Applicant’s Signature Spring ____/_____ Summer _______/_______
(19) Are you using your G.I. Benefits or eligible for GI Benefits: Yes_____ NO_____
Sworn to (or affirmed) before me this
___________day of ___________ 20_____
___________________________________
Notary Public
Certificate Issued ( ) Certificate Not Issued ( )
Number of Months _______________
Date: ________________ By _____________________
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 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
60 days prior thereto or 30 days after the start of the semester, and such certificate of residence shall be valid for a period of one year from the
date of issuance. Education Law, Section 6301, paragraph 4 defines “Resident” A person who has resided in this 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 6 months both immediately preceding the date of such
person’s registration in a community college or, for the purposes of section 6305 of this chapter, his/her application for a certificate of residence.
According to Article 126 of Education Law, Section 6301 paragraphs 5, 5(i), 5(ii) and 5(iii) 1 & 2, “In the event that a person qualified for state residence but has been
a resident of two or more counties in the state during the six months immediately preceding his application for a certificate of residence, the charges to the counties of
residence shall be allocated among the several counties proportional to the number of months, or major fraction thereof, of residence in each county.”
OFFICE USE ONLY
NYS LICENSE
ISSUE DATE:
________________
RPS
VOTER REG
MAIL
______________
______________