937.328.6034 | ﬁnancialaid@clarkstate.edu | 570 East Leel Lane, Springﬁeld, Ohio 45505
SECTION D: Identity and Statement of Educational Purpose (Required to be signed at the Financial
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 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 ocial at the institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional ocial, the Statement of
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 driver’s
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 ocial seal:
__________________________ My commission expires on _____________________
(Notary signature) (Date) (Place Seal Here)