Affidavit And Application For Certificate Of Residency Form

Affidavit And Application For Certificate Of Residency Form - Wayne County

Wayne County

Wayne County Treasurer

(315) 946-7441

PO Box 8

16 Williams St

Lyons, NY

14489

Website:

Contact:

Thomas Warnick

The attached application/affidavit must be completed and presented to the above address

with the appropriate proof. The County needs this form in order to determine your eligibility

for a Certificate.

Requirements:

•

Application (must be filled out at the Town Clerk’s Office. Exception of the Town of

Lyons and Town of Newark. Students must sign their signature in front of the Notary

Public)

•

Driver’s license or permit

•

Two forms of proof (one year in NY State; 6 months in Wayne County)

Acceptable proof (examples):

•

High school transcript (if you were enrolled in a high school in the county’s school

district within the past year).

•

Mail post-marked 12 and/or 6 months prior to class starting (must be street address,

not a PO BOX address).

Certificate must be obtained within the time period of 60 days before the first day of class but

no later than 30 days after the first day of class.

The original Certificate of Residence (not this application) can be delivered to any of the three

TC3 locations: Ithaca Extension Center, Cortland Extension Center or the main campus or it

can also be mailed to:

Tompkins Cortland Community College

Room #215

170 North Street, PO 139 Dryden, NY 13053.

Note: faxes or photocopies are NOT acceptable.

7/22/2005

Affidavit And Application For Certificate Of Residency Form - Wayne County