(CHERRY) 15-16 Identity – Stmt of Edu Purpose Form 2/27/2015
Financial Aid Office P.O. Box 804 Spindale, NC 28160
Identity/Statement of Educational Purpose - 2015-2016
Full Name: ____________________________ Student ID: _____________ Date of Birth: ___/___/____
Instructions: You must appear in person at ICC to verify your identity by presenting valid government-issued photo
identification (ID). Examples of accepted forms of ID are listed in section A below. The institution will maintain a copy of
your photo ID that is annotated with the date it was received and the name of the official at ICC authorized to collect the
student’s ID.
Signature Requirement:
You must sign, in the presence of the ICC official, the statement in section B, or.
If you cannot appear in person, you must send us a readable photocopy of the acceptable Photo ID, and you must
sign, in the presence of a notary, the statement in section B.
A. VERIFICATION OF GOVERNMENT ISSUED ID (Notary, check which document is copied for review)
Driver’s License Non-Driving State ID Military ID Passport
B. SIGNATURE(S)
I certify that I _________________________________ am the individual signing this Statement of
(Print Student’s Name)
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 ICC for 2015-2016.
STUDENT SIGNATURE DATE
NOTARY SIGNATURE (If applicable) DATE
Notary’s Certificate of Acknowledgement
State of _____________________________________ City/County of
________________________________________________
On_________________, before me, _____________________________, personally appeared, ____________________________
(Date) (Notary’s name) (Printed name of signer)
and provided to me on basis of satisfactory evidence of identification (indicated in Section A above) to be the above-named
person who signed the foregoing instrument.
Verified by: ______________ Date: _________
Notary Stamp or Seal
(If Applicable)
My commission expires on:
Date
