Financial Aid
937.328.6034 | financialaid@clarkstate.edu | 570 East Leel Lane, Springfield, Ohio 45505
1
2020-2021 Verification Worksheet
V4 – Custom Group
Your 2020-2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a
process called verification. Clark State Community College is required to collect the following
information and compare it to the information reported on the FAFSA. If any discrepancies are
found, we will make the corrections to your FAFSA. No federal financial aid will be oered until all
discrepancies have been resolved and the FAFSA has been corrected.
SECTION A: Student Information
Name____________________________________________ Student ID Number___________________
Address
_____________________________________________________________________________________
Street City State Zip
Home Phone __________________________________ Work Phone _____________________________
SECTION B: High School Completion Status (REQUIRED)
Provide one of the following documents to indicate the student’s high school completion status
when the student begins college in 2020–2021:
A copy of the student’s high school diploma.
For students who completed secondary education in a foreign country, a copy of the “secondary
school leaving certificate” or other similar document.
A copy of the student’s final ocial high school transcript that shows the date when the diploma
was awarded.
A state certificate or transcript received by a student after the student passed a State-authorized
examination that the State recognizes as the equivalent of a high school diploma (GED test, HiSET,
TASC, or other State authorized examination).
An academic transcript that indicates the student successfully completed at least a two-year
program that is acceptable for full credit toward a bachelors degree.
For a student who was homeschooled in a state where state law requires the student to obtain a
secondary school completion credential for homeschooling (other than a high school diploma or
its recognized equivalent), a copy of that credential.
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. A student who is unable to obtain the documentation listed above must contact the
financial aid oce.
SECTION C: Certification Statement
I certify that all of the information on this form and accompanying documents are true and complete
to the best of my knowledge. Furthermore, I arm that I have not knowingly or intentionally provided
any false or fraudulent documentation.
Student Signature ___________________________________________ Date_____________________
Parent Signature (if parent information is provided) ___________________________ Date_________
Financial Aid
FAC20VG4
Financial Aid
937.328.6034 | financialaid@clarkstate.edu | 570 East Leel Lane, Springfield, Ohio 45505
2
SECTION D: Identity and Statement of Educational Purpose (Required to be signed at the Financial
Aid Oce)
The student must appear in person at Clark State Community College to verify his or her identity by
presenting an unexpired valid government-issued photo identification (ID), such as, but not limited
to, a drivers 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 ocial at the institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional ocial, the Statement of
Educational Purpose.
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 Clark State Community College for 2020–2021.
_____________________________________ ___________________ _________________________
Student’s Signature Date Student’s ID Number
OFFICE USE ONLY
I certify that I have received a valid copy of unexpired identification.
_______________________________________________________________________________
Print Financial Aid Sta Member Name Signature Date
If the student is unable to appear in person at Clark State Community College to verify his or her
identity, the student must provide to the institution:
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 drivers
license, other state-issued ID, or passport; and
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.
Notary’s Certificate of Acknowledgement:
State of ______________________ City/County of ___________________On_____________________,
before me, _______________________________, personally appeared, ______________________and
(Notary’s Name) (Printed name of signer)
proved to me on the basis of satisfactory evidence of identification_________________________ to be
(Type of government-issued photo ID provided)
the above-named person who signed the foregoing instrument.
WITNESS my hand and ocial seal:
__________________________ My commission expires on _____________________
(Notary signature) (Date) (Place Seal Here)
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