Confirmation of Citizenship/Immigration
Document Statement
Name:_____________________________________________ 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.
Certification Statement
I certify that I, _____________________________________________________________________________
(Print Name)
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):
TYPE OF VALID PHOTO
ID
EXPIRATION DATE OF VALID
PHOTO ID
ISSUING AUTHORITY OF VALID
PHOTO ID
TYPE 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: _______________________
