ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
Rev. March 14, 2019
2019-2020 Selective Service Verification
ICC Student ID #______________
Financial aid applicants who are male and born after December 31, 1959
are required to register with the Selective Service System.
Your financial aid application cannot be processed because your Selective Service registration could not be confirmed.
Processing will continue after you submit documentation of proof of registration or exemption and complete this form. If
you have any questions, please contact the Financial Assistance Office.
Please check the statement that describes your circumstance.
☐ I am a female and I am not required to register with the Selective Service.
☐ I have not reached my 18
birthday, but will register with the Selective Service within 30 days of my 18
☐ I was born before January 1, 1960.
☐ I am a veteran of active duty in the U.S. Armed Forces (National Guard or Reserves are not included).
Attached is a copy of my DD-214. (If you do not have a copy, you can obtain a copy by contacting the
Veterans Administration at 1-800-827-1000.)
☐ I am registered with Selective Service. Attached is documentation of my registration status. (If you do
not have a copy of your registration, you can log in to the Selective Service web page at www.sss.gov or
by calling 1-847-688-6888).
☐ I am not required to register for Selective Service based on the fact that I entered the United States after my 26
birthday. Attached is a copy of my date-stamped I-94 or port of entry papers.
☐ None of the above statements accurately describes my circumstance. I have attached a copy of my status letter
acknowledging the reason for non-registration status along with a detailed explanation below, if additional space
is needed please continue on the back of this page. (Please contact the Selective Service at www.sss.gov or
1-847-688-6888, to request a Status Letter.)
By signing this form, you are certifying that all the
information reported on it is complete and correct.
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.
WARNING: If you purposely give false or misleading
information on this worksheet, you may be fined, be
sentenced to jail, or both.