OFFICE OF FINANCIAL AID
Identity and Statement of Educational Purpose Form 2019-2020
(To be Signed with Notary)
STUDENT NAME: _____________________________________ DATE: ______________
The Office of Financial Aid at Purdue University Northwest will request this documentation only if it is needed to complete your financial aid
file. Verification is a process required by the U. S. Department of Education to review the accuracy of information reported on the Free
Application for Federal Student Aid (FAFSA). Further processing of your financial aid will not occur until the information requested below has
been received by the Office of Financial Aid.
DIRECTIONS: If the student is unable to appear in person at Purdue University Northwest 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 ___________________________________ 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 Purdue University Northwest 2019-2020
CERTIFICATION: (Provide required signature, date and PUID certifying information provided is complete and correct)
Student Signature: ______________________________________ Date: _________________
PUID: ______________________________________________
Notary’s Certificate of Acknowledgement
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 identification _______________________________________
(Type of government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal _____________________________________
(seal) (Notary signature)
My commission expires on _________________________
(Date)
Office Use Only – RRAAREQ: ___ISPN20 (R)
Hammond Campus
2200 169th Street * Hammond, IN 46323
(219)) 989-2301* FAX: (219) 989-2141
Westville Campus
1401 S. U.S. Hwy. 421 * Westville, IN 46391
(219) 785-5460 * FAX: (219) 785-5653
Toll-Free: 1-855-608-4600
website: pnw.edu
