Fillable IIDIIIITM)I UNIVERSITY ARKANSAS 2021-2022 Identity and Statement of

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IIDIIIITM)I UNIVERSITY ARKANSAS 2021-2022 Identity and Statement of

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UNIVERSITY
OF
ARKANSAS
IIDIIIITM)I
~
■
1100 Co
ll
ege Drive I Mena, Arkansas
71
953
Phone: 479.39
4.7
622 I Fax: 479.39
4.5
329 I www.uaric
hm
ountain.e
du
OFFICE OF FINANCIAL AID
2021-2022 Identity and Statement of Educational Purpose
➢ The student must appear in person at UA Rich Mountain to verify his or her 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.
If the student is unable to appear in person at UA Rich Mountain, the student must appear in person with a Notary Public to
verify his or her identity by presenting a valid government issued photo identification (ID) as requested above.
➢ The Institution will maintain this original statement signed by an authorized official at the institution or by a Notary
Public with a copy of the student’s photo ID that is annotated with the date it was received and reviewed and the name of
the official at the institution authorized to collect the student’s ID.
Statement of Educational Purpose
I certify that I,
(Print Student’s Name)
am the individual signing this Statement of Educational Purpose and that the Federal Student Aid I may receive will only
be used for educational purposes and to pay the cost of attending UA Rich Mountain for 2021-2022.
(Student Signature)
(Student SSN)
(Date)
Declaración de Propósito Educativo
Certifico que yo,
[Imprimir Nombre del Estudiante]
soy el individuo que firma esta Declaración de Finalidad Educativa y que la ayuda financiera federal estudiantil que yo
pueda recibir, sólo será utilizada para fines educativos y para pagar el costo de asistir a UA Rich Mountain para 2021-2022
[Firma del Estudiante]
[Número de Identificación del Estudiante]
[la Fecha]
Notary’s Certificate of Acknowledgement
State of
City/County of
On
(Date)
before me,
personally appeared,
, and provided to me
(Notary’s Name)
(Printed name of signer)
on the basis of satisfactory 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
My commission expires on
(Seal)
Notary signature
(Date)
FOR OFFICE USE ONLY:
I verify that the student provided a valid photo ID.
Signature/Title of UA Rich Mountain official
Date
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Completed 29 January 2021

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