Certificate Of Residency Application printable pdf download

Certificate Of Residency Application

Thomas A. Warnick

APPLICATION FOR WAYNE COUNTY

OUNTY

REASURER

-----------------------

315-946-7443

Certificate of Residency

315-946-5949

FAX

WWW

WAYNE

Issued by Chief Fiscal Officer of Wayne County

Pursuant to Sections 6301 and 6305 of the Education Law

Social Security Number: _______ - _______ - _______

Student: (

please print name) ________________________________________

I plan to enroll in __________________________________

College, and I do hereby state that my legal permanent address is as

follows:

_______________________________________________________

(Street Address)

_________________________, NY _______________, County of Wayne

(Town or Village)

(Zip Code)

I further state that I have lived at the above address for: _________________

(length of time)

If less than one year at the above address, please state your previous

address and length of time at this address: ___________________

Applicant’s Signature: ________________________, DATE: __________

Office use only:

Sworn to (or affirmed) before me this

Signature check: ( )

_____ day of _________, 20____

Certificate issued for _____ months

_____________________

Date: ________Issued by:______

(Notary Public)

Certificate Of Residency Application