BARUCH COLLEGE/CUNY RESIDENCY FORM
Residency Unit
151 East 25th Street, Box H-0720, New York, NY 10010
[email protected]
CUNY RESIDENCY FORM: Part A
1. Last Name __________________________ First Name _______________ Middle Initial _______
2. CUNYfirst ID/Student ID _____________________ Date of Birth ________________________
Phone No.( ) _____________ Email address: ____________________________________
3. Are you a U.S. citizen? Yes No Are you a permanent resident alien? Yes No
Are you here on a visa? Yes No Visa type: _______ Expiration Date: ______________
4. Did you attend a New York State high school for two or more years, and graduate from that high
school?
Yes No If yes, high school name and address __________________________________
Date of Attendance From: _________ To: _________ Graduation Date _____________________
5. Do you have a GED/TASC issued by NYS? Yes No Date Issued:_________________
6. If you answered “yes” to item 4 or 5, did you apply to CUNY within 5 years of your high school
graduation or receiving a GED/TASC? Yes No Date of first application to CUNY: ________
7. Are you a veteran or other individual eligible for educational assistance under federal GI bills?
Yes _____No ____ If yes, attach supporting documents.
IMPORTANT: If you answered “yes” to question 4 or 5, and to question 6, and are not lawfully present in the US, you
need to complete Section B (affidavit) of this Residency Form but not Section C. If you answered “yes” to question 4 or
5, and to question 6, and are a resident of another state, you do not need to complete any other sections of this form. If
you answered “yes” to question 7, you do not need to complete any other sections of this form. All other students must
complete Part C of this form and submit appropriate supporting documentation.
Please note that some students who are here on visas may not be eligible for the resident tuition rate. Please refer to
the CUNY Tuition and Fee Manual (see link below) for a comprehensive list of eligible visa types.
To Be Completed by All Students
I certify that all information provided and all statements made in all sections of this Residency Form are true and correct
to the best of my knowledge.
I understand that if I provide false information or withhold relevant information in order to obtain resident status, The City
University may revoke its determination of in-state residency, and that I will owe non-resident tuition to the University for
each semester or session that I have attended under these circumstances. I also understand that I may be subject to
disciplinary action.
DATE _______________________ STUDENT SIGNATURE ________________________________
The colleges will not review any residency determination unless the request for the review is made in writing, and all
required documentation is submitted on or before the last day of finals in the semester for which resident tuition is
being sought.
Complete rules regarding eligibility for the resident tuition rate and appeals procedure are set forth in CUNY’s Tuition
and Fee Manual at http://www.cuny.edu/about/administration/offices/la/tuition-fee-manual.html
Semester: ____________
CUNY RESIDENCY FORM: Part B
Affidavit of Intent to Legalize Immigration Status
_____________________________, being duly sworn, deposes and says that he/she does not currently
(Student’s Name)
have lawful immigration status but, has filed an application to legalize his/her immigration status or will file
such an application as soon as he/she is eligible to do so.
__________________________________
(Student’s Signature)
Sworn to me this _________________day of the month of _______________ ,20___
______________________, State of New York, County of _____________________.
CUNY RESIDENCY FORM: Part C
1. Last Name ____________________________ First Name _______________ Middle Initial ______
2. CUNYfirst ID/Student ID______________ Email: ________________________________________
3. Current Address ______________________________ ________________ ________ _________
STREET CITY STATE ZIP
A. Live with parents _________, or other relatives _________, or other than a relative ___________
1) If other relatives, describe relationship. ______________________________________________
2) If other than a relative, describe situation. ___________________________________________
_____________________________________________________________________________
List below all your addresses, including temporary addresses and summer addresses during the past 12
months, starting from your current address and working backwards.
FROM TO COMPLETE ADDRESS
Mo __ Day __ Yr __ Mo __ Day __ Yr __ ____________________________________________
STREET
____________________________________________
CITY STATE ZIP
Mo __ Day __ Yr __ Mo __ Day __ Yr __ ____________________________________________
STREET
____________________________________________
CITY STATE ZIP
Mo__ Day __ Yr __ Mo __ Day __ Yr __ ____________________________________________
STREET
____________________________________________
CITY STATE ZIP
4. A. Parents' permanent address _____________________________________________________
STREET
_____________________________________________________
CITY STATE ZIP
B. If you are under the age of 18, does anyone other than your parents serve as your legal
guardian? Yes____ No_____
If yes, what is their name and address? ____________________________________________
____________________________________________________________________________
C. Where did you live during the last June through August period? If different from 4.A., give
reason for being elsewhere during period
____________________________________________________________________________
____________________________________________________________________________
Semester: ____________
- page 2 of Part C-
5. A. Please list below all full-time and part-time employment (including summer employment and
voluntary activities) during the past 12 months starting with the most recent employment.
EMPLOYER ADDRESS (CITY/STATE) FROM TO
_______________________ ___________________________ __________ _________
_______________________ ___________________________ __________ _________
_______________________ ___________________________ __________ _________
B. What is the source of your support?_________________________________________________
C. Did you file a New York City/State resident income tax return during the past 12 months? ______
D. Did you file a Federal income tax return during the past 12 months? ______________________
6. What are your purposes for residing in New York City or New York State?_____________________
7. Have you applied for any financial aid, scholarships, or other benefits provided under the laws of
the State of New York or the United States? Yes _____ No _____
If yes, specify and indicate what benefits you are receiving. __________________________________
__________________________________________________________________________________
8. At the present time is it your intention to permanently live in New York City or New York State?
Yes _____ No _____ Uncertain _____ If uncertain, please explain. __________________
__________________________________________________________________________________
9. Do you have any other proof other than the items indicated for completing the Residency Form that
you wish to present in support of your application to be declared a resident of New York City/New
York State for the City University of New York tuition purposes? Yes _____ No ____
If yes, please provide details and attach relevant documents.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________