Lorain County Community College Financial Services 1005 N. Abbe Rd, Elyria, OH 44035 Phone: 440-366-4034
Identity and Statement of Educational Purpose Form
2020-21 Financial Aid Year
Last Name First Name Middle Initial
LCCC Student ID #
Option #1—Identity and Statement of Educational Purpose (to be signed at the institution)
The student must appear in person at Lorain County Community College 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. The institution will maintain a copy of the
student’s 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, the student must sign, in the presence of the institutional official, the following:
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 financial assistance I may receive will only be used for educational purposes and to pay the cost of attending Lorain County
Community College for 2020-21.
__________________________________ ____________ _________________ __________________________________
Student’s Signature Date Student’s ID Number Authorized Institutional Official
(signature/printed name)
Option #2—Identity and Statement of Educational Purpose (to be signed with notary)
If the student is unable to appear in person at Lorain County Community College to verify his or her identity, the student must provide:
a) A copy of the valid government-issued photo identification (ID) that is acknowledged in the notary statement below, such as but not
limited to a driver’s license, other state-issued ID, or passport; and
b) The original notarized Statement of Educational Purpose provided below.
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 financial assistance I may receive will only be used for educational purposes and to pay the cost of attending Lorain County
Community College for 2020-21.
Student Signature ____________________________________ Student’s ID # ____________________ Date __________________
Notary’s Certificate of Acknowledgement
State of ____________________________ City/County of ____________________________________ on ______________ (date)
before me, ____________________________________________, personally appeared ___________________________________
(Notary’s name) (Printed name of signer)
and provided to me on basis of satisfactory evidence of identification _______________________________________ to be the
(Type of government-issued photo ID provided)
above-named person who signed the foregoing instrument.
WITNESS my hand and official seal ________________________________________
(Notary signature)
My commission expires on _________________________
(Date)
If you complete this form via notary, submit the original completed form and the identification presented at the notary by mail to the address
below or deliver to Financial Services, First Floor, Bass Library. If not completing at a notary, you must appear in person at Financial Services. The
form must be signed by an authorized Financial Services staff member. This document cannot be faxed or submitted electronically.
seal
