IDENTITY & STATEMENT OF EDUCATIONAL PURPOSE FORM
(MUST BE SIGNED AT CCC Lone Tree Campus)
(2020-2021 Academic Year – V4, V5)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 . email@example.com
You must appear in person at Coconino Community College to verify your identity by presenting a valid
government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID,
or passport. CCC will maintain a copy of your photo ID that is annotated with the date it was received and the
name of the official at the institution authorized to collect the student’s ID.
In addition, you must sign, in the presence of the institutional official, the following:
Statement of Educational Purpose
I certify that I, am the individual signing this
Print Student’s Name)
Statement of Educational Purpose and that the federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending Coconino
Community College for 2020-2021.
I certify that the information provided on this form is complete and accurate to the best of my
knowledge. I understand that submission of false information may result in a delay or denial of federal
financial aid and may subject me to criminal charges. I understand that purposely giving false or
misleading information may result in a fine of up to $20,000, being sent to prison, or both.
Student’s Signature Date
CCC Certification of Signature
On this, the day of , 20 , ,
(Print Student’s Name)
personally appeared before me and signed this document. He/She provided satisfactory documentation
of photo identification to be the person whose name is listed on this document.
I have made a high quality photocopy of the photo identification, submitted with this form.
CCC Financial Aid Staff Signature Date
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address