"Student Self Certification" - New York

Student Self Certification is a legal document that was released by the New York State Homes and Community Renewal - a government authority operating within New York.

Form Details:

  • Released on January 1, 2019;
  • The latest edition currently provided by the New York State Homes and Community Renewal;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the New York State Homes and Community Renewal.

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Download "Student Self Certification" - New York

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STUDENT SELF CERTIFICATION
This annual Student Self Certification is in connection with the undersigned’s application/occupancy in the following apartment:
Head of Household Name:
Unit No. if assigned:
Development Name and Address:
Move-in Date if applicable:
Effective Date:
Check A, B, or C as applicable (note that students include those attending public or private elementary schools, middle or junior
high schools, senior high schools, colleges, universities, technical, trade, online, or mechanical schools, but does not include those
attending on-the-job training courses):
A.
_____
Household contains at least one occupant who is not a student and has not been/will not be a student for five
months or more out of the current and/or upcoming calendar year (months need not be consecutive). If this item
is checked, no further information is needed (Do not answer questions 1-5). Sign and date below.
B.
_____
Household contains all students, but is qualified because the following occupant(s)
___________________________________ is/are a PART-TIME student(s) who have not been/will not be a full
time student for five months or more of the current and/or upcoming calendar year. Verification of part-time
student status is required for at least one occupant. If this item is checked, no further information is needed (Do
not answer questions 1-5). Sign and date below.
C.
_____
Household contains all students who were, are, or will be FULL-TIME for five months or more out of the
current and/or upcoming calendar year (months need not be consecutive). If this item is checked, questions 1-5
below must be completed:
1.
Is any member married and entitled to file a joint tax return? (attach marriage certificate or tax return)
YES
NO
2.
Is at least one student a single parent with child(ren) and this parent is not a dependent of someone
YES
NO
else, and the child(ren) is/are not dependent(s) of someone other than a parent? (attach student’s most
recent tax return and, if applicable, divorce/custody decree or other parent’s most recent tax return)
3.
Is at least one student receiving Temporary Assistance to Needy Families (TANF)? (provide release of
YES
NO
information for verification purposes)
4.
Does at least one student participate in a program receiving assistance under the Workforce Innovation
YES
NO
and Opportunity Act or under other similar federal, state, or local laws? (attach verification of
participation)
5.
Does the household consist of at least one student who has ever been under the care and placement
YES
NO
responsibility of the state agency responsible for administering foster care? (provide verification of
participation)
Full-time student households satisfy one of the above conditions are considered eligible. If C is checked and questions 1-5 are marked NO or
verification does not support the exception indicated, the household is considered ineligible.
Under penalties of perjury, I/we certify that the information presented in this Annual Student Certification is true and accurate to
the best of my/our knowledge and belief. I/we agree to notify management immediately of any changes in this household’s
student status. The undersigned further understands that providing false representations herein constitutes an act of fraud. False,
misleading, or incomplete information may result in the termination of the lease agreement.
All household members age 18 or older must sign and date.
Printed Name
Signature
Date
Printed Name
Signature
Date
Printed Name
Signature
Date
Printed Name
Signature
Date
Student Self Certification (2019)
STUDENT SELF CERTIFICATION
This annual Student Self Certification is in connection with the undersigned’s application/occupancy in the following apartment:
Head of Household Name:
Unit No. if assigned:
Development Name and Address:
Move-in Date if applicable:
Effective Date:
Check A, B, or C as applicable (note that students include those attending public or private elementary schools, middle or junior
high schools, senior high schools, colleges, universities, technical, trade, online, or mechanical schools, but does not include those
attending on-the-job training courses):
A.
_____
Household contains at least one occupant who is not a student and has not been/will not be a student for five
months or more out of the current and/or upcoming calendar year (months need not be consecutive). If this item
is checked, no further information is needed (Do not answer questions 1-5). Sign and date below.
B.
_____
Household contains all students, but is qualified because the following occupant(s)
___________________________________ is/are a PART-TIME student(s) who have not been/will not be a full
time student for five months or more of the current and/or upcoming calendar year. Verification of part-time
student status is required for at least one occupant. If this item is checked, no further information is needed (Do
not answer questions 1-5). Sign and date below.
C.
_____
Household contains all students who were, are, or will be FULL-TIME for five months or more out of the
current and/or upcoming calendar year (months need not be consecutive). If this item is checked, questions 1-5
below must be completed:
1.
Is any member married and entitled to file a joint tax return? (attach marriage certificate or tax return)
YES
NO
2.
Is at least one student a single parent with child(ren) and this parent is not a dependent of someone
YES
NO
else, and the child(ren) is/are not dependent(s) of someone other than a parent? (attach student’s most
recent tax return and, if applicable, divorce/custody decree or other parent’s most recent tax return)
3.
Is at least one student receiving Temporary Assistance to Needy Families (TANF)? (provide release of
YES
NO
information for verification purposes)
4.
Does at least one student participate in a program receiving assistance under the Workforce Innovation
YES
NO
and Opportunity Act or under other similar federal, state, or local laws? (attach verification of
participation)
5.
Does the household consist of at least one student who has ever been under the care and placement
YES
NO
responsibility of the state agency responsible for administering foster care? (provide verification of
participation)
Full-time student households satisfy one of the above conditions are considered eligible. If C is checked and questions 1-5 are marked NO or
verification does not support the exception indicated, the household is considered ineligible.
Under penalties of perjury, I/we certify that the information presented in this Annual Student Certification is true and accurate to
the best of my/our knowledge and belief. I/we agree to notify management immediately of any changes in this household’s
student status. The undersigned further understands that providing false representations herein constitutes an act of fraud. False,
misleading, or incomplete information may result in the termination of the lease agreement.
All household members age 18 or older must sign and date.
Printed Name
Signature
Date
Printed Name
Signature
Date
Printed Name
Signature
Date
Printed Name
Signature
Date
Student Self Certification (2019)