Residence Statement
82-06-15 (4/93)-1Ob
NEW YORK STATE
DEPARTMENT OF ENVIRONMENTAL CONSERVATION
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RESIDENCE STATEMENT
COUNTY OF
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Issuing Agent
STATE OF NEW YORK
I. ' do hereby affirm that I have been
a resident of ~ew York State for the 30 days immediately preceding the execution of this affirmation.
yly legal residence is at:
Street
City
NY
Zip Code
I hereby affirm under penalty of perjury that the information provided on this form is true. False statements made
on instruments submitted pursuant to the Environmental Conservation Law are punishable as a Class A misdemeanor
pursuant to Section 210.45 of the Penal Law.
Signature of Resident
Date