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INDEPENDENT STATEMENT OF EDUCATIONAL PURPOSE AND CONFIRMATION OF (Florida Institute of Technology)

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444-0719
Page 1 of 3
Florida Institute of Technology
■
Oce of Financial Aid
150 West University Boulevard, Melbourne, FL 32901-6975
■
321-674-8070
■
Fax 321-724-2778
naid@t.edu
INDEPENDENT STATEMENT OF EDUCATIONAL PURPOSE
AND CONFIRMATION OF IDENTITY 2019–2020
(To be signed in the presence of a notary)
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (To Be Signed at the Institution)
The student must appear in person at Florida Institute of Technology to verify his or her identity by presenting an unexpired valid
government-issued photo identication (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 ocial at the institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional ocial, the Statement of Educational Purpose provided below.
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 Florida Institute of Technology to verify his or her identity, the student must provide to the
institution:
A. A copy of the unexpired valid government-issued photo identication (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 sepa-
rate page than the Statement of Educational Purpose, there must be a clear indication that the Statement of Educational Purpose
was the document notarized.
STATEMENT OF EDUCATIONAL PURPOSE
I certify that I, __________________________________________________________, am the individual signing this Statement
of Educational Purpose and that the federal student nancial assistance I may receive will only be used for educational
purposes and to pay the cost of attending ________________________________________ for 2019–2020.
__________________________________________________ __________________________________________________ _______________
Student’s Handwritten Signature Student ID Number Date
Print Student’s Name
Name of Postsecondary Institution
444-0719
Page 2 of 3
Florida Institute of Technology
■
Oce of Financial Aid
150 West University Boulevard, Melbourne, FL 32901-6975
■
321-674-8070
■
Fax 321-724-2778
naid@t.edu
VERIFICACIÓN DE IDENTIDAD Y DECLARACIÓN DE PROPÓSITO EDUCATIVO (PARA SER FIRMADAS EN LA INSTITUCIÓN)
El estudiante debe comparecer en persona en Florida Institute of Technology para vericar su identidad mediante la present-
ación de una identicación con fotografía (ID) válida emitida por el gobierno que no haya expirado, como una licencia de conducir,
otro tipo de identicación emitida por el estado o pasaporte, entre otros. La institución conservará una copia de la identicación
con fotografía del estudiante en la cual se anotará la fecha en la que se recibió y revisó, y el nombre del funcionario de la institución
autorizado a recibir y revisar las identicaciones de los estudiantes.
Además, el estudiante debe rmar, en presencia del funcionario de la institución, la Declaración de Propósito Educativo proporcio-
nada a continuación.
VERIFICACIÓN DE IDENTIDAD Y DECLARACIÓN DE PROPÓSITO EDUCATIVO (PARA SER FIRMADAS EN PRESENCIA DE UN NO-
TARIO)
Si el estudiante no es capaz de comparecer en persona en Florida Institute of Technology para vericar su identidad, el mismo
debe proporcionar a la institución:
A. una copia de la de identicación con fotografía (ID) válida emitida por el gobierno que no haya expirado, que se reconoce en la
declaración del notario que aparece a continuación, o que se presenta ante un notario, como una licencia de conducir,otro tipo de
identicación emitida por el estado o pasaporte, entre otros; y
B. la Declaración de Propósito Educativo original proporcionada a continuación debe ser notarizada. Si la declaración del notario
aparece en una página separada de la Declaración de Propósito Educativo, se debe indicar de manera clara que la Declaración de
Propósito Educativo era el documento notarizado.
DECLARACIÓN DE PROPÓSITO EDUCATIVO
Certico que yo, __________________________________________________________, soy el individuo que rma esta
Declaración de Finalidad Educativa y que Ia ayuda nanciera federal estudiantil que yo pueda recibir, sólo será utilizada
para nes educativos y para pagar el costo de asistir a _____________________________________ para 2019–2020.
__________________________________________________ __________________________________________________ _______________
Firma del Estudiante Número de Identicación del Estudiante La Fecha
lmprimir Nombre del Estudiante
lmprimir Nombre de lnstitucion Educativa Postsecundaria
INDEPENDENT STATEMENT OF EDUCATIONAL PURPOSE
AND CONFIRMATION OF IDENTITY 2018–2019
(To be signed in the presence of a notary)
444-0719
Page 3 of 3
Florida Institute of Technology
■
Oce of Financial Aid
150 West University Boulevard, Melbourne, FL 32901-6975
■
321-674-8070
■
Fax 321-724-2778
naid@t.edu
SAMPLE OF A NOTARY’S CERTIFICATE OF ACKNOWLEDGEMENT
(Notary’s certication may vary by state)
State of ________________________________________________________________________
City/County of ___________________________________________________________________
On_____________________, before me, ____________________________________________,
(Date) (Notary’s name)
Personally appeared, ____________________________________________, and provided to me
(Printed name of signer)
on basis of satisfactory evidence of identication _______________________________________
(Type of unexpired government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and ocial seal
(seal) _______________________________________
My commission expires on _________________________
(Date)
YOU MUST MAIL THIS
ORIGINAL COPY OF THE
NOTARIZED STATEMENT
TO THE FINANCIAL AID
OFFICE AT THE ADDRESS
BELOW. FEDERAL
GUIDELINES PRECLUDE
US FROM ACCEPTING
A FAXED COPY OR AN
EMAIL ATTACHMENT OF
YOUR CERTIFICATION.
INDEPENDENT STATEMENT OF EDUCATIONAL PURPOSE
AND CONFIRMATION OF IDENTITY 2019–2020
(To be signed in the presence of a notary)
(Notary signature)
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Completed 29 January 2021

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