Citizenship and Immigration Status Confirmation
Student Name: Student ID:
This form is for the collection of Department of Homeland Security (DHS) or other U.S. citizenship/nationality
documents from students unable to present their documents in person. 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 am providing.
List of Document(s):
Name of Valid ID
Expiration Date of Valid 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)
Notary’s Certificate of Acknowledgement
State of _____________________________________________
City/County of ________________________________________
On ____________________________, before me, ________________________________________________,
personally appeared ______________________________________________, and proved to me on basis of
satisfactory evidence of identification _____________________________________________________ to be the
above-named person who signed the foregoing instrument.
WITNESS my hand and official seal ______________________________________________________
My commission expires on ______________________________
Statement of Certification
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.
Students Signature Date
*Note: Must be signed in the presence of a Notary Public.
(Print student’s full name)
(Notary’s Name)
(Student’s Printed Name)
(Type of government issued photo ID provided)
(Notary’s Signature)
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