This form is for the collection of DHS or other U.S. citizenship/nationality documents from students unable to
present their documents in person.
I certify that I, , am the individual signing this statement, and I am providing a
(Print Student’s Name)
copy of my documents along with a copy of a valid government-issued photo identification card bearing my
portrait (or likeness).
I certify that the attached documents and government issued photo identification are the true, exact, and
complete copies of the originals issued to me.
I understand that providing false or misleading information or documents is punishable by fine or imprisonment
and may make me liable for repayment of any funds received on the basis of the information and documents I
have provided.
STUDENT SIGNATURE DATE
*Sign in the presence of a notary public
Notary’s Certificate of Acknowledgement
State of
City/County of /
Sworn to and subscribed before me this, the
day of , 20 .
PRINTED NOTARY NAME DATE
NOTARY SIGNATURE DATE
Please return this completed form to: GTCC Financial Aid Office, PO Box 309, Jamestown, NC
27282 or FAX to 336-217-8468.
Financial Aid Office P.O. Box 309
Phone: 336.334.4822 Option 3
Jamestown, NC
27282 Fax: 336.217.8468
CERTIFICATION OF TRUE, EXACT, AND COMPLETE COPY OF THE ORIGINAL DOCUMENTS
Notary Stamp or Seal
My commission expires on the following
date:
