Application Form For Certificate Of Residence Page 2
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1
2
3APPLICATION FOR CERTIFICATE OF RESIDENCE
Pursuant to sections 6301 & 6305 of the Education Law
Tompkins County Finance Department
125 E. Court Street, Ithaca, NY 14850
(607) 274-5545
Certificate of residence shall be valid for a period of one year from the semester of issuance unless otherwise noted.
Certificate of residence will not be issued earlier than two months prior to the first day of classes.
SEMESTER (Fall/Spring/Summer) _________________YEAR_______
PLEASE PRINT
STUDENTS NAME __________________________________________________________________________
Last
First
M.I.
Social Security #
LOCAL ADDRESS:__________________________________________________________________________
Street Address
Town
State
Zip Code
County
STUDENT
I, THE UNDERSIGNED, PLAN TO ENROLL AT _____________________________
Name of college
AFFIRMATION:
I AFFIRM THAT MY LEGAL/PERMANENT RESIDENCE IS:
ADDRESS: _________________________________________________________________________________
Street Address
Town
State
Zip Code
County
I have resided at the above address from _____/____/_____ to present.
IF LESS THAN FOUR (4) YEARS PLEASE LIST ALL OTHER ADDRESSES AND DATES.
Previous Address:
Dates:
____________________________________________________________________________________________
____________________________________________________________________________________________
____________________________________________________________________________________________
I am currently enrolled in:
Cornell University? Yes / No
Ithaca College? Yes / No
YES
NO
ARE YOU A UNITED STATES CITIZEN:
or
(please circle one)
IF NO:
VISA TYPE ________ OTHER STATUS__________RESIDENT ALIEN CARD#________________
IF NOT A UNITED STATES CITIZEN MUST SHOW CARD
__________________________________________________
Student Signature
Date
Phone Number (_____)______________________
Sworn before me this ____day of
________________________20_____.
****************************************
_______________________________.
County Use Only - Verification
Notary Public
Identification: ______________________________
Proof:
______________________________
______________________________
Certificate Issued ________________ Certificate Denied _______________
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