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P0204092020
2019-2020 CITIZEN/ELIGIBLE NON-CITIZEN AFFIDAVIT
AND COPY CERTIFICATION
Based upon information provided to you in your Student Aid Report, the Department of Education has requested additional
documentation regarding your citizenship status. Please gather your original citizenship documentation and complete this
form. The original citizenship documentation must be certified by you as true, exact, and complete copies.
A. Student Information
STUDENT NAME: _______________________________________________ GCU STUDENT NUMBER: _________________________
Address: ______________________________________________________ Date of Birth: ___________________________________
City: __________________________ State: ___________ Zip: ___________ Phone No.:_____________________________________
B. Student Affidavit
I certify that I, _____________________________, am the individual signing this statement, and I am providing copies of my
citizenship document(s) noted below to Grand Canyon University. I certify that the citizenship document(s) are the true,
exact, and complete copies of the originals issued to me.
NOTE: Complete both the “Type of Citizenship…” and “Expiration Date…” sections below.
TYPE OF CITIZENSHIP AND/OR IMMIGRATION DOCUMENT(S)
(e.g. U.S. Passport, Certificate of Naturalization)
EXPIRATION DATE (IF ANY) OF CITIZENSHIP
AND/OR IMMIGRATION DOCUMENT(S)
C. Student Signature
I understand that providing false or misleading information or documentation is punishable by fine or imprisonment and may
make me liable for repayment of any funds received on the basis of the information and documentation I have provided.
Student Signature: ______________________________________
_ Date: ____________________________
* Signing electronically via Adobe is acceptable
click to sign
signature
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