Custom Verication Form
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 identication (ID), such as, but not limited to, a drivers
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 ocial at the
institution authorized to receive and review the students ID.
In addition, the student must sign, in the presence of the institutional ocial, 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
Student Full Name (Please Print)
The student must appear in person at
Name of Postsecondary Educational Institution
Notarys Certicate 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 Certicate of Acknowledgement statement.
State of
County of
Today’s Date
, before me,
Notarys Name
, personally appeared,
Name of Signer
, and provided to me on a basis of satisfactory evidence of identication
Type of Photo ID Provided
to be the above named person who signed the foregoing instrument.
WITNESS my hand and ocial seal:
Notary Signature Student Signature
Updated 3/19