04_2020
CERTIFICATION OF TRUE, EXACT, AND COMPLETE COPY OF THE ORIGINAL DOCUMENTS
To be completed and signed by the student and submitted with the citizenship documentation
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.
(Print student’s full name)
I certify that the attached document(s)are the true, exact, and complete copies of the originals issued to
me.
List of document(s):
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’s Signature
________________________________
Date
WAYS TO SUBMIT THIS FORM
(1) Upload the form at www.virginiawestern.com by clicking ‘Contact Us,’ and then clicking the 24/7 Student Support
icon. Once you log in you can submit documents (2) Fax forms to 540-857-6208
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Phone: (855)874-6690
