2020-2021
Form #4 - Custom Verification Worksheet
Your Free Application for Federal Student Aid (FAFSA) was selected for review process called Verification.
In this process we compare
your FAFSA with information on this worksheet and other required documents, such
as your 2018 IRS tax information. The Financial Aid
Staff will not make any financial aid payments to you until all verification and required documentation have been met and the necessary
correction have been made under the
financial aid program regulation (34CFR, art 668).
STUDENT INFORMATION
Last Name (Please Print) First Name
M.I.
Date of Birth
Peralta Student ID
Last 4-digits of SSN
Telephone Number to best reach you
STUDENT HIGH SCHOOL COMPLETION STATUS
Provide one of
the following documents that indicate you have, or will have a high school diploma or
GED
at
the
time you
begin taking
classes at Peralta Community College District. Peralta
Community
College District consists
of the following colleges: Berkeley City College,
College of Alameda, Laney College and Merritt College. Please
check the box indicating the document you are providing:
Copy of your high school diploma
Copy of your final official high school transcript that shows the date the diploma was awarded
Copy of your General Educational Development (GED) certificate or GED transcript
An academic transcript that indicates that you successfully completed at least a two-year co
llege program that is acceptable for
full credit toward a bachelor’s degree (Please note: this option will take additional time in completing your verification
for the evaluation of your transcripts)
If a State law requires a homeschooled student to obtain a secondary school completion credential for
homeschool (other than a high
school diploma or its recognized equivalent), a copy of that credential or a copy of your
transcript or equivalent signed by a parent or guardian
I do NOT have a high school diploma or GED.
If you are unable to obtain the documentation listed
above, please contact the financial aid office. An additional form and/or
alternative documentation may be accepted.
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (TO BE SIGNED IN PERSON AT
THE CAMPUS FINANCIAL AID OFFICE)
You must appear in person at your home Financial Aid Office within the Peralta Community College District (PCCD) to verify your identity
by presenting a valid government-issued photo identification ID such as, but not limited to, a driver’s license, other state-issued ID, or
passport (note: Military ID cannot be accepted). The institution
will maintain a
copy of your photo ID that is annotated by the institution
with the date it was received and reviewed along with the
name of the official at the institution authorized to collect your ID.
In addition, the student must sign, in the presence of the institutional official, the Statement of Educational Purpose provided below.
Statement of Educational Purpose: (To Be Signed in the presence of the Institutional Official)
I certify that I
am the individual signing this Statement of Educational
Print Name
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 PCCD for the 2020-2021 Award Year.
Student signature
Date
For Office Use Only/Date and Initials
Rev. 5/22/20 JV
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE
(TO BE SIGNED WITH A NOTARY)
If the student
is unable t
o appear in pe
rson
at
one of
the
Peralta
Community
College campus Financial Aid Offices to verify your identity, the
student must provide:
a)
A copy of
the valid government iss
ue
d
pho
to
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 (note: Military ID cannot be
accepted); and
b)
The original Statement of
Education Purpo
se
provided
below
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 Purpose and that the
Print Name
federal student financial assistance I may receive will only be used for educational purposes and to pay the cost of attending Peralta Community
College District for 2020-2021.
Student Signature
Date
Peralta Student ID
Notary’s Certifica
te of Acknowledg
ement
State/of
City/County/
of On
, before me,
,
personally appeared,
, and provided to me on basis of
Printed Name of Signer
satisfactory evidence of identification
Type of government-issued photo ID provided
to be the above-named person who signed the
WITNESS my hand and official seal
:
My commission expires on
Date
CERTIFICATION AND SIGNATURE
By signing below,
I/we c
ertify the information
reported on
this
worksheet is complete and accurate and authorize the Financial Aid Office to perform
necessary electronic ISIR correction on my behalf. I/we agree to provide proof of any information reported on this form or on my FAFSA. I/we realize that
any false statement or failure to give proof when asked may be cause for denial, reduction, withdrawal, and/or repayment of my financial aid. I/we also
understand if we purposely give false or misleading information I/we may be fined, sentenced to jail or both. If you are an independent and married student, a
spouse signature is optional. If you are a dependent student, one parent must sign below.
Student signature Date Spouse Signature (if married) or Parent Signature (if a dependent student) Date
Berkeley City College
2050 Center Street
Berkeley, CA
510.981.2805
College of Alameda
555 Ralph Appezzato Mem.Pkwy
Alameda, CA 94501
510.748.2228
Laney College
900 Fallon Street
Oakland, CA 94607
510.464.3314
Merritt College
12500 Campus Drive
Oakland, CA 94619
510.436.2465
Rev. 5/22/2020 JV
Date
Notary Name
Notary signature
oregoing instrument.