20192020 Identity and Statement of Educational Purpose
(To Be Signed in the Presence of a Notary)
Mail this original form AND a copy of the ID that is acknowledged in the statement to
: Indian Hills Community College,
Attn: Financial Aid, 525 Grandview Avenue, Ottumwa, Iowa 52501.
Student’s Name
_____________________________________________ Student’s ID Number _________________
If the student is unable to appear in person at _______________________________________
(Name of Postsecondary Educational Institution)
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
(
Print Student’s Name)
this Statement of 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
__________________________________________________________ for 20192020.
(Name of Postsecondary Educational Institution)
_______________________________________ _______________
(Student’s Signature) (Date)
______________________
(Student’s ID Number)
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
(Printed name of signer)
on the basis of 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)
Indian Hills Community College
Indian Hills Community College
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