KELLOGG
COMMUNITY COLLEGE
2019-2020
Custom Verication Form
(VD4/V14)
Identity and Statement of
Educational Purpose
Student ID#
Identity and Statement of Educational Purpose (to be signed at the institution)
to verify his or her identity by
presenting an unexpired valid government-issued photo identication (ID), such as, but not limited to, a driver’s
license, other state-issued ID, or passport. The institution will maintain a copy of the student’s photo ID that is
annotated by the institution with the date it was received and reviewed, and the name of the ocial at the
institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional ocial, the Statement of Educational
Purpose provided below.
I certify that I, , am the individual signing this Statement of Education
Purpose and that the federal student nancial assistance I may receive will only be used for education purposes
and to pay the cost of attending Kellogg Community College for 2019-2020.
Student Signature
Date
Student Full Name (Please Print)
The student must appear in person at
Name of Postsecondary Educational Institution
APPROVED Sta Name
OR
Notary’s Certicate of Acknowledgement
If you, the student, are not able to appear in person at Kellogg Community College, to verify your identity,
you must complete and submit this Notarized Certicate of Acknowledgement statement.
State of
County of
On
Today’s Date
, before me,
Notary’s Name
, personally appeared,
Name of Signer
, and provided to me on a basis of satisfactory evidence of identication
Type of Photo ID Provided
to be the above named person who signed the foregoing instrument.
WITNESS my hand and ocial seal:
Notary Signature Student Signature
Updated 3/19
