2020-2021 Dependent
V4 Custom Verification Worksheet
Louisiana College Financial Aid Office 1140 College Dr Box 582 Pineville, La. 71359
Phone (318) 487-7386 Fax (318) 487-7449 Email: financial_aid@lacollege.edu
https://www.lacollege.edu/students/financial-aid/
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(Print Student’s Name)
DO NOT COMPLETE THIS FORM IN ADVANCE
B. Identity and Statement of Educational Purpose (To be signed at the institution)
The student must appear in person at Louisiana College to verify his or her identity by presenting an unexpired
valid government-issued photo identification (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 official at the institution authorized to
receive and review the student’s ID. In addition, the student must sign, in the presence of the institutional official,
the Statement of Educational Purpose provided below.
C. Identity and Statement of Educational Purpose (To be signed in the presence of a notary)
If the student is unable to appear in person at Louisiana 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.
D. Statement of Educational Purpose
I certify that I ________________________________________ am the individual signing 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 Louisiana College for 2020-2021.
________________________________________________________________ ___________________
(Student’s Signature) (Date)
_________________________
(Student’s ID Number)
E. Notary’s Certificate of Acknowledgement
State of _______________________________________ City/Parish of ___________________________________
On_____________________, before me, _____________________________________________, personally appeared,
(Date) (Notary’s name)
____________________________________________________, and provided to me on the basis of satisfactory
(Printed name of signer)
evidence of identification ______________________________________________ to be the above-named person who
(Type of unexpired government-issued photo ID provided)
signed the foregoing instrument.
WITNESS my hand and official seal
(Seal) _________________________________________________
(Notary Signature)
My commission expires on ______________________
A. Student Information
Student’s Name: ________________________________________________
LC ID: ______________________
Clear Form
2020-2021 Dependent
V4 Custom Verification Worksheet
Louisiana College Financial Aid Office 1140 College Dr Box 582 Pineville, La. 71359
Phone (318) 487-7386 Fax (318) 487-7449 Email: financial_aid@lacollege.edu
https://www.lacollege.edu/students/financial-aid/
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F. High School Completion Status
High School Graduate/Equivalency Check the box of the document you will attach to this worksheet:
The original high school diploma or official high school transcript which includes the graduation date
The student’s original General Education Development (GED) certificate, an official GED transcript that indicates the student
passed the exam, or an original state-authorized high school equivalent certificate.
Students who completed secondary education in a foreign country, a copy of the “secondary school leaving certificate” or
other similar document*
Official academic transcript of a completed two-year program acceptable for full credit toward a bachelor’s degree
For a student who was homeschooled in a State where State law does not require the student to obtain a secondary school
completion credential for homeschooling (other than a high school diploma or its recognized equivalent), a transcript, or the
equivalent, signed by the student’s parent or guardian, that lists the secondary school courses the student completed and
includes a statement that the student successfully completed a secondary school education in a homeschool setting.
Non High School Graduate:
I do not meet any of the statements above. Students who do not have a high school diploma or its equivalent and are beyond
the age of compulsory education are not eligible to receive financial aid unless they meet certain eligibility criteria regarding
prior college enrollment and may be considered under former Ability-to-Benefit (ATB) regulations. The Financial Aid Office
will determine if you meet these requirements.
Did you attend college classes prior to July 1, 2012? YES NO
Major/Program of Study: ___________________
College Name*: _____________________________________________
*If you did not attend LC, you must attach official college transcript(s).
Did you officially register for college prior to July 1, 2012? YES NO
College Name: ______________________________________________ Major/Program of Study: ___________________
Are you currently enrolled in an eligible career pathway? YES NO
G. Certification and Signatures Each person signing this worksheet certifies that all of the information reported on it is
complete and correct. The student and one parent whose information was reported on the FAFSA must sign and date. Warning! If
you purposely give false or misleading information you may be fined, sentenced to jail, or both.
Student Signature: _____________________________________________________ Date__________________
This worksheet must be signed and dated to be valid. Electronic and/or digital signatures are not valid.
For Office Use Only
Identity and Statement of Educational Purpose:
Copy of original unexpired valid government-issued photo identification (ID) presented to institutional official (financial aid staff)
Identification Type:
Institutional Official Name:
Institutional Official Signature: Date:
High School Completion Status:
Acceptable documentation in file
Approved
Comment(s):
Processed/Reviewed By:
Date:
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