Fillable 2020-2021 IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (Illinois Central College)

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2020-2021 IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (Illinois Central College)

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ICC Financial Assistance Office
1 College Drive
Eas
t Peoria, IL 61635-0001
Phone: (309) 694-5
600
Fax: (309) 694-
5160
email: financialaid@icc.edu
Revised April 16, 2020
2020-2021 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 Purpose
(Print Student’s Name)
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 2020–2021.
Student Signature
Date
ICC Student ID
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.
Notary’s Certificate of Acknowledgement
Notary’s certification may vary by State
State of ___________________________________________
City/County of ______________________________________
On_________________, before me, ____________________________, personally appeared, _______________________________,
(Date) (Notary’s name) (Printed name of signer)
and proved to me 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
__________________________________________________
(Notary signature)
My commission expires on _____________________________
(Date) (seal)
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ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-
0001
Phone: (309) 694-5
600
Fax: (309) 694-
5160
email: financialaid@icc.edu
Revised April 16, 2020
2020-2021 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, otr
o
t
ipo 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 2020–2021.
Firma del estudiante
Fecha
ICC [Número de identificación del estudiante]
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.
Notary’s Certificate of Acknowledgement
Notary’s certification may vary by State
State of ___________________________________________
City/County of ______________________________________
On_________________, before me, ____________________________, personally appeared, _______________________________,
(Date) (Notary’s name) (Printed name of signer)
and proved to me 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
__________________________________________________
(Notary signature)
My commission expires on _____________________________
(Date) (seal)
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2020-2021 IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (Illinois Central College)

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Completed 25 July 2020

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