2020-21 IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE
(TO BE SIGNED IN THE PRESENCE OF A NOTARY)
If the student is unable to appear in person at Central Community 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
Print Student’s Name
the individual signing this
Statement of Educational Purpose
and that the Federal student
financial assistance I may receive will only be used for educational purposes and to pay
the cost of attending Central Community College for 2020-21.
__________________________________________________________________________________
STUDENT SIGNATURE CCC STUDENT ID NUMBER DATE
**********************************************************************
N
OTARY’S CERTIFICATE OF ACKNOWLEDGEMENT
State of _________________________________ City/County of ______________________________
On ____________________, before me, _________________________________________________
Date Notary’s Name
personally appeared, _______________________________________________, and proved to me on
Printed Name of Signer
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
(seal)
_____ _________________________________________________________________
NOTARY SIGNATURE MY COMMISSION EXPIRES ON
Please return this form to the Financial Aid Office at the location you plan to attend:
Central Community College – Columbus PO Box 1027 Columbus, NE 68602-1027
Central Community College – Grand Island PO Box 4903 Grand Island, NE 68802-4903
Central Community College – Hastings PO Box 1024 Hastings NE 68902-1024
Central Community College – Kearney PO Box 310 Kearney, NE 68848-0310
