HVCC Financial Aid Office Phone 518-629-7150 Guenther Room 110
80 Vandenburgh Ave Monday-Friday
Troy, NY 12180 8AM-5PM
Mastrangelo Financial Aid Center
Affidavit for Citizenship Documentation
PLEASE NOTE: You must return this ORIGINAL form by mail. We CANNOT accept copies via fax or
CERTIFICATION OF TRUE, EXACT, AND COMPLETE COPY OF THE ORIGINAL DOCUMENTS
This form is for the collection of DHS or other U.S. citizenship/nationality documents from students unable to present their
documents in person.
I certify that I, __________________________, am the individual signing this statement and I am providing a copy of my documents
along with a copy of a valid government-issued photo identification card bearing my portrait (or likeness).
I certify that the attached documents and government issued photo identification are the true, exact, and complete copies of the
originals issued to me.
List of document(s):
EXPIRATION DATE OF PHOTO ID
ISSUING AUTHORITY OF VALID PHOTO ID
NAME OF CITIZENSHIP AND/OR IMMIGRATION
DOCUMENT(S)
EXPIRATION DATE (IF ANY) OF
CITIZENSHIP AND/OR IMMIGRATION
DOCUMENT(S)
I understand that providing false or misleading information or documents is punishable by fine or imprisonment and may make me
liable for repayment of any funds received on the basis of the information and documents I have provided.
Student Signature: __________________________________________ Date: ___________________________
Notary’s Certificate of Acknowledgement
State of _________________________________________City/County of _____________________________________
on_____________________, before me, __________________________________________, personally appeared,
(Date) (Notary’s name)
_______________________________________, and proved to me on basis of satisfactory evidence of identification
(Printed name of signer)
__________________________________ to be the above-named person who signed the foregoing instrument.
(Type of government-issued photo ID provided)
WITNESS my hand and official seal _______________________________________________
(Notary signature)
My commission expires on _________________________
(Date)
PLEASE NOTE: You must return this ORIGINAL form by mail. We CANNOT accept copies via fax or email.
