2015-2016 Identity and Statement of Educational Purpose Verification

2015-2016 Identity and Statement of Educational
Purpose Verification
Financial Aid Office
(To be signed at the Institution)
A. Student Information (Please print. Please use black ink.)
___________________________________________________
_____________________________________
First Name
JCCC ID #
Birthdate ______________________
Last Name
_______
M.I.
B. Identity and Statement of Educational Purpose (To be signed at the Institution)
The student must appear in person at JOHNSON COUNTY COMMUNITY COLLEGE to verify his or her identity by presenting a
valid government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID or passport.
The institution will maintain a copy of the student’s photo ID that is annotated by the institution with the date it was received and
reviewed, and the name of the official at the institution authorized to collect the student’s ID.
In addition, the student must sign, in the presence of the institutional official, the following English or Spanish statement.
Statement of Educational Purpose
I certify that I, ___________________________________ am the individual signing this Statement of Educational
(Print Student’s Name)
Purpose and that the federal student financial assistance I may receive will only be used for educational purposes and
to pay the cost of attending JOHNSON COUNTY COMMUNITY COLLEGE for 2015-2016.
__________________________________________________ Student’s Signature*
________________________
Date
Student’s ID Number
Declaración de Propósito Educativo
Certifico que yo ___________________________________ soy el individuo que firma esta Declaración de Finalidad
(Imprimir Nombre del Estudiante)
Educativa y que la ayuda financiera federal estudiantil que yo pueda recibir, sólo será utilizada para fines educativos y
para pagar el costo de asistir a JOHNSON COUNTY COMMUNITY COLLEGE para 2015-2016.
__________________________________________________ [Firma del Estudiante)*
[Número de identificatión del estudiante]
*Electronic signatures will not be accepted.
________________________
[la Fecha]
FOR OFFICE USE ONLY
___ This form must be signed in person by the student.
___ Student must sign and produce a government-issued photo ID.
___ Make a copy of the ID and attach it to this form.
CLEAR FORM
IDED16 (11/14)
___ Date and sign that you saw the original.