Fillable 19 20 Statement Educational Purpose Notary (Jacksonville University)

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19 20 Statement Educational Purpose Notary (Jacksonville University)

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2800 University Boulevard N | Jacksonville, FL 32211
T 800.558.3467 | F 904.256.7148 Page 1 of 2
2019-2020 Statement of Educational Purpose
Student’s Last Name First Name M.I. Student’s Identification (ID) Number
Student’s Street Address (include apt. no.) Student’s Date of Birth
City State Zip Code Student’s Email Address
Student’s Home Phone Number (include area code) Student’s Alternate or Cell Number
IDENTI
TY AND STATEMENT OF EDUCATIONAL PURPOSE
(To Be Signed With Notary)
If the student is unable to appear in person at Jacksonville University to verify his or her identity, the
student must provide:
(a) A
copy of the valid government-issued photo identification (ID) that is acknowledged in the
notary statement below, such as, but not limited to a driver’s license, other state-issued ID, or
passport; and
(b) The original notarized Statement of Educational Purpose provided below.
Statement of Educational Purpose
I certify that I _____________________________ am the individual signing this
(Print Student’s Name)
Statement of Educational 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 __________________________________________________________ for
2019-2020. (Name of Postsecondary Educational Institution)
________________________________________ _______________
(Student’s Signature) (Date)
_____________________
(Student’s ID Number)
Nota
ry’s Certificate of Acknowledgement on page 2
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Student’s Name___________________________________________ Student’s ID Number ___________________
28
00 University Boulevard N | Jacksonville, FL 32211
T 800.558.3467 | F 904.256.7148 Page 2 of 2
No
tary’s Certificate of Acknowledgement
St
ate of ________________________________________________________________________
Ci
ty/County of ___________________________________________________________________
On_______________
______, before me, ____________________________________________,
(Date) (Notary’s name)
per
sonally appeared, ____________________________________________, and provided to me
(Printed name of signer)
on
basis of satisfactory evidence of identification _______________________________________
(Type of government-issued photo ID provided)
to
be the above-named person who signed the foregoing instrument.
WI
TNESS my hand and official seal
(seal) ________________________________________
(Notary signature)
My
commission expires on _____________
____________
Certifications and Signatures
Each person signing below certifies that all of the
information reported is complete and correct.
The student and one parent whose information was
reported on the FAFSA must sign and date.
_______________
____________________________ _________________________
Print Student’s Name Student’s ID Number
_______________
___________________________ _________________________
Student’s Signature Date
_______________
___________________________ _________________________
Parent’s Signature Date
WARNING: If you purposely give false
or misleading information you may be
fined, be sentenced to jail, or both.
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19 20 Statement Educational Purpose Notary (Jacksonville University)

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Completed 21 July 2020

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