ICC Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5
Fax: (309) 694-
email: financialaid@icc.edu
Revised April 16, 2020 KR
Student Name:
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 18th birthday, but will register with the Selective Service within 30 days of my 18th birthday.
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 login 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 26th 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 a
blank page and include your name and ICC student ID at the top. (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.
FEDERAL WARNING: If you purposely give false or misleading information on this form; you may be fined, be sentenced to jail, or both.
Student Signature
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.
click to sign
click to edit