___________________________ __________
NOTARY’S CERTIFICATE OF ACKNOWLEDGEMENT (ONLY NECESSARY IF NOT completing in person at LCCC.)
State of __________________________, City/County of ___________________________________ on _____________
(Date)
before me, ___________________________________, personally appeared ___________________________________
(Printed name of Notary) (Printed name of signer)
and proved to me on basis of satisfactory evidence of identification __________________________________________
(Type of unexpired government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal _____________________________________________
(seal) (Notary Signature)
My commission expires on _______________________
(Date)
OFFICE OF FINANCIAL AID
4525 Education Park Drive, Schnecksville, PA 18078
P 610
.799.1133| F 610.799.1798
E finaid@mymail.lccc.edu
2019-20 Proof of Identity & Statement of Educational Purpose
DO NOT FILL IN THIS WORKSHEET UNLESS YOU ARE IN THE PRESENCE OF AN
LCCC FINANCIAL AID REPRESENTATIVE OR A NOTARY PUBLIC!
Student Name Student ID
1. Valid Photo Documentation of Identity
If completing with an LCCC Financial Aid representative hand your photo ID to the representative to copy, then
complete Step 2 on the copied document in their presence - OR - If you are completing this form in the presence of a
notary public you will need to attach a copy of your valid photo 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, to this worksheet.
IF COMPLETING IN PERSON AT LCCC:
LCCC Financial Aid representative: place
valid (unexpired) government-issued photo
identification (ID) over this space and make a
photocopy of this form.
Student will then complete the Statement of
Educational Purpose on the copied document.
If the student’s ID does not fit in the space provided,
attach an annotated copy of the ID to this form.
Proof of identification received and reviewed by:
_________ ___
Print First & Last Name of LCCC Representative Date
2. Statement of Educational Purpose and Signature
I certify that I _____________________________ am the individual signing this Statement of Educational Purpose and
Print Student’s Name
that the Federal student financial assistance I may receive will only be used for educational purposes and to pay the cost
of attending Lehigh Carbon Community College for 2019-20.
Student’s Signature Date
IMPORTANT: Student, mail this ORIGINAL notarized document AND the copy of your
proof of identification to Financial Aid. Copies or faxes CANNOT be accepted!
