(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
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
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
My commission expires on: