ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
email: financialaid@icc.edu
Rev. March 14, 2019
2019-2020 Identity and Statement of Educational Purpose
(Sign in the presence of a Notary)
If the student is unable to appear in person at Illinois Central College to verify his or her identity, the student must provide
to the institution:
(a) A copy of the unexpired valid government-issued photo identification (ID) that is acknowledged in the notary
statement below, or that is presented to a notary, such as, but not limited to, a driver’s license, other state-issued ID, or
passport; and
(b) The original Statement of Educational Purpose provided below, which must be notarized. If the notary statement
appears on a separate page than the Statement of Educational Purpose, there must be a clear indication that the
Statement of Educational Purpose was the document notarized.
Statement of Educational Purpose
I certify that I ______________________________________ am the individual signing this Statement of Educational
(Print Student’s Name)
Educational Purpose and that the federal student financial assistance I may receive will only be used for educational
purposes and to pay the cost of attending Illinois Central College for 20192020.
It is the policy of this College that no person, on the basis of race, color, religion, gender, national origin, age, disability,
sexual orientation, or veteran’s status, shall be discriminated against in employment, in educational programs and
activities, or in admission. Inquiries and complaints may be addressed to the Compliance Officer, Diversity Department.
____________________________________________ ____________________________ ______________________
(Student Signature) (Date) (ICC Student ID #)
Notary’s Certificate of Acknowledgement
Notary’s certification may vary by State
State of ______________________________________________
City/County of ______________________________________________
On_____________________, before me, ___________________________________________________,
(Date) (Notary’s name)
personally appeared, __________________________________________, and proved to me on the basis of
(Printed name of signer)
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)
ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
email: financialaid@icc.edu
Rev. March 14, 2019
2019-2020 Identidad y Declaración de Propósito Educativo
(Para ser firmadas en presencia de un notario)
Si el estudiante no es capaz de comparecer en persona en Colegio Central de Illinois para verificar su identidad, el mismo
debe proporcionar a la institución:
(a) una copia de la de identificación con fotografía (ID) válida emitida por el gobierno que no haya expirado, que se
reconoce en la declaración del notario que aparece a continuación, o que se presenta ante un notario, como una
licencia de conducir, otro tipo de identificación emitida por el estado o pasaporte, entre otros; y
(b) la Declaración de Propósito Educativo original proporcionada a continuación debe ser notarizada. Si la declaración
del notario aparece en una página separada de la Declaración de Propósito Educativo, se debe indicar de manera clara
que la Declaración de Propósito Educativo era el documento notarizado.
Declaración de Propósito Educativo
Certifico que yo, __________________________, soy el individuo que firma esta Declaración de Propósito Educativo,
[Imprimir nombre del estudiante]
y que la ayuda financiera federal estudiantil que yo pueda recibir sólo será utilizada para fines educativos y para pagar el
costo de asistir a Colegio Central de Illinois para 20192020.
Es política de este Colegio que ninguna persona, en base a raza, color, religión, género, origen nacional, edad, discapacidad, orientación sexual o
condición de veterano, será discriminada en el empleo, en programas y actividades educativas, o en la admisión. Las consultas y quejas pueden
dirigirse a la Oficina de Cumplimiento, Departamento de Diversidad.
______________________________________ _______________________ _______________________________
[Firma del estudiante] [Fecha] [ICC número de identificación del estudiante]
Notary’s Certificate of Acknowledgement
Notary’s certification may vary by State
State of ______________________________________________
City/County of ______________________________________________
On_____________________, before me, ___________________________________________________,
(Date) (Notary’s name)
personally appeared, __________________________________________, and proved to me on the basis of
(Printed name of signer)
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)
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