937.328.6034 | ﬁnancialaid@clarkstate.edu | 570 East Leel Lane, Springﬁeld, Ohio 45505
SECTION F: 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.
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)