Fillable 2015 16 Citizenship Affidavit (California Lutheran University)

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2015 16 Citizenship Affidavit (California Lutheran University)

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California Lutheran University – Office of Financial Aid
2015-16 Citizenship Affidavit
RETURN TO:
CLU Office of Financial Aid
60 West Olsen Road #1375
Thousand Oaks, CA 91360
EMAIL: finaid@callutheran.edu
This form is for the collection of DHS or other U.S. citizenship/nationality documents
from students unable to present their documents in person.
Certification of true, exact, and complete copy of the original documents
I certify that I, _____________________________________________________________ am the individual signing this
(Print Student’s Full Name)
statement, and I am providing a 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.
List of document(s):
Name of Valid Photo ID
Expiration Date of Valid Photo ID
Issuing Authority of Valid Photo ID
Name of Citizenship and/or Immigration Document(s)
Expiration Date (if any) of Citizenship and/or
Immigration Document(s)
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’s Signature - Required
Date
Notary’s Certificate of Acknowledgement
State of
City/County of
On
, before me,
(Date)
(Notary’s Name)
Personally appeared,
, and provided to me on basis of satisfactory
(Printed Name of Signer)
evidence of identification
(Type of Government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
Notary’s Signature
Seal
My commission expires on
Date
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2015 16 Citizenship Affidavit (California Lutheran University)

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Completed 21 July 2020

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