Fillable Dependent V4 (California State University Channel Islands)

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Dependent V4 (California State University Channel Islands)

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FA-25 / 18-19 Page 1 of 2
2018-2019 Verification Worksheet
Dependent - Custom Verification Group (V4)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
Student Last Name
Student First Name
CSUCI ID Number
Student Phone Number
DO NOT SUBMIT THIS FORM UNLESS IT WAS REQUESTED BY OUR OFFICE
Purpose
Your 2018-2019 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. You and at least one
parent must complete and sign this worksheet, attach any required documents, and submit the form and other required documents to the Financial
Aid & Scholarships office. We may also ask for additional information upon further review. If you have special circumstances or require further
instructions, please contact our office at financial.aid@csuci.edu or (805) 437-8530.
A. High School Completion Status
Please check the box (ONLY ONE) that indicates the student’s high school completion status:
High School Diploma
Please submit:
A copy of the student's high school diploma; or
A copy of the student's final high school transcript that shows the date when the diploma was awarded
State Certificate (includes GED)
Please submit:
A copy of the certificate/transcript the student received after passing a state-authorized examination, which the state recognizes as the
equivalent of a high school diploma (GED test, HiSET, TASC, or other State-authorized examination)
Two-Year Program Completion
Please submit:
A copy of the student's academic transcript that indicates the student has completed at least a two-year program that is acceptable for
full credit toward a bachelor's degree
Foreign Country Secondary School Leaving Certificate
Please submit:
A copy of the student’s “secondary school leaving certificate” or other similar document
Home Schooled Student
Please submit:
When State law requires the student to obtain a secondary school completion credential for homeschooling:
A copy of that credential
When State law does not require the student to obtain a secondary school completion credential for homeschooling:
A transcript or the equivalent, signed by the student's parent or guardian, that lists the secondary school courses the student has
completed and documentation that the student has successfully completed secondary school education in a homeschool setting
NOTE: If the student is unable to obtain the documentation requested to support their high school completion status, or, the student has
provided this information in a prior year, the student must contact the Financial Aid & Scholarships office.
B. Certification and Signature
The student and one parent must sign and date below. Each person signing this worksheet certifies that all of the information reported on this form is
true and accurate to the best of their knowledge.
WARNING:
If you purposely give false or
misleading information on this
form, you may be fined, sentenced
to jail, or both.
Student Signature (electronic signatures not accepted)
Date
Parent Signature (electronic signatures not accepted)
Date
FA-25 / 18-19 Page 2 of 2
2018-2019 Verification Worksheet
Dependent - Custom Verification Group (V4)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
C. Identity and Statement of Educational Purpose
Identity and Statement of Educational Purpose (To Be Signed at the Institution)
The student must appear in person at California State University Channel Islands (CSUCI) to verify his or her identity by presenting an unexpired
valid government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID, or passport. The institution will
maintain a copy of the student’s photo ID that is annotated by the institution with the date it was received and reviewed, and the name of the official
at the institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional official, the Statement of Educational Purpose provided below.
I certify that I,
, am the individual signing this Statement of Educational Purpose and that the Federal student
(Print Student's Name)
financial assistance I may receive will only be used for educational purposes and to pay the cost of attending California State University Channel Islands
(CSUCI) for 2018-2019.
Student Signature
Date
Student’s ID Number
Financial Aid Administrator Signature
Date
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 California State University Channel Islands (CSUCI) 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.
I certify that I,
, am the individual signing this Statement of Educational Purpose and that the Federal student
(Print Student's Name)
financial assistance I may receive will only be used for educational purposes and to pay the cost of attending California State University Channel Islands
(CSUCI) for 2018-2019.
Student Signature
Date
Student’s ID Number
Notary’s Certificate of Acknowledgement
State of
City/County of
on
before me
personally appeared
and proved to me on the basis of satisfactory
(Notary’s Name)
(Printed name of signer)
evidence of identification,
, to be the above-named person who signed the foregoing instrument.
(Type of government-issued photo ID provided)
WITNESS my hand and official seal
(seal)
(Notary Signature)
(Date commission expires)
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Dependent V4 (California State University Channel Islands)

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Completed 24 July 2020

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