AFFIDAVIT (OR AFFIRMATION) AND APPLICATION FOR CERTIFICATE OF RESIDENCE, PURSUANT TO 
SECTIONS 6301 AND 6305 OF THE EDUCATION LAW, IN CONNECTION WITH ATTENDANCE AT ORANGE 
COUNTY COMMUNITY COLLEGE* 
STATE OF NEW YORK, Semester: Fall_________________ Spring____________________ 
COUNTY OF _______________ Summer I __________II__________III______________ 
Name____________________________________________ Social Security #___________________________________________ 
Address: Dates of Residency 
_______________________________________________________________________________ From___/___/__ To___/___/___ 
Street City State Zip County 
Previous (If less than 2 years at current) 
_______________________________________________________________________________ From___/___/__ To___/___/___ 
_______________________________________________________________________________ From___/___/___To___/___/___ 
Mailing Address:___________________________________________________________________________________________ 
(If Different Than Above) 
Citizenship: U.S. Citizen _________Other __________ Visa Type ___________________________________ 
Permanent Resident Alien#______________________ Date of Issue ________________________________ 
ATTACH A COPY OF YOUR PERMANENT RESIDENT ALIEN CARD (IF APPLICABLE) 
I hereby swear (or affirm) that I reside at the above stated address; that I now am and have for a period of at least one year immediately 
prior to the date of this affidavit (or affirmation) and application; been a legal resident of the State of New York; that I now am and 
have been for a period of at least six (6) months** immediately prior to the date of this affidavit (or affirmation) and application, a 
legal resident of the County of _______________. I further state I plan to enroll in Orange County Community College and that this 
affidavit (or affirmation) and application is made for the sole purpose of securing from the Chief Fiscal Officer of the County 
of________________________ a certificate of residence pursuant to the requirements of Article 126 of the Education Law. 
I hereby swear (or affirm) that I reside legally at the above home address and that I have, for two years immediately prior to the date 
of this affidavit (or affirmation) and application, resided as stated above. 
________________________________________ ___________________ 
Signature of Applicant Date 
Sworn to (or affirmed) before me this 
________ day of ______________, 20________ 
________________________________ 
Notary Public or Commissioner of Deeds 
*EDUCATION LAW, SECTION 6305, PROVIDES: �THE CHIEF FISCAL OFFICER OF EACH COUNTY, AS DEFINED IN SECTION2.00 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 THAT TWO MONTHS PRIOR THERETO , 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 THE STATE FOR A PERIOD OF AT LEAST ONE YEAR AND IN THE COUNTY, 
CITY, TOWN, INTERMEDIATE SCHOOL DISTRICT OF SCHOOL DISTRICT, AS THE CASE MAY BE, OR A PERIOD OF AT LEAST SIX 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 APPLICATION FOR A CERTIFICATE OF RESIDENCE. 
**IN THE EVENT THAT A PERSON QUALIFIED AS ABOVE FOR STATE RESIDENCE,, BUT HAS BEEN A RESIDENT OF TWO OR MORE COUNTIES IN THE STATE DURING THE SIX MONTHS 
IMMEDIATELY PRECEDING HIS/HER APPLICATION FOR A CERTIFICATE OF RESIDENCE PURSUANT TO SECTION 6305 OF THIS CHAPTER, 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. 
___________________________________________________________________________________________________________ 
THIS SPACE FOR USE OF CHIEF FISCAL OFFICER OF COUNTY 
CERTIFICATE ISSUED( ) CERTIFICATE DENIED( ) 
DATE___________________BY_______________________