CITIZENSHIP AND IMMIGRATION
STATUSNOTARIZED
This form is for the collection of DHS or other U.S. citizenship/nationality documents from students unable to present their documents in person
at a Brandman University campus. Send this form and the below referenced copied documents to the Brandman Financial Aid Office. You can
upload all pages via the Student Portal at Brandman.edu.
I certify that I, ________________________________________________________________, am the individual signing this
(Print full name)
statement, and I am providing (1) a copy of my documents along with (2) a copy of a valid government-issued photo identification
card such as a driver’s license or State ID.
NOTE: It is unlawful to photocopy Military ID, therefore it may not be used for this purpose.
NAME OF VALID PHOTO ID
(Driver’s license or State ID)
EXPIRATION DATE OF VALID PHOTO ID
ISSUING AUTHORITY OF VALID PHOTO ID
(state or federal)
NAME OF CITIZENSHIP AND/OR IMMIGRATION
DOCUMENT(S)
EXPIRATION DATE (IF ANY) OF CITIZENSHIP AND/OR
IMMIGRATION DOCUMENT(S)
I certify that the attached documents and government issued photo identification are the true, exact, and complete copies of the originals issued to
me. I understand that providing false or misleading information or documents is punishable by fine or imprisonment and may make me liable for
repayment of any funds received on the basis of the information and documents I have provided.
________________________________ __________________________________ __________________
Student’s Handwritten Signature Student’s ID Number Date
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)
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