STUDENT FINANCIAL SERVICES
2020-2021
SELECTIVE SERVICE REQUEST
MTC ID Number
I am requesting a Status Information Letter. All of the following are true:
I have passed my 26
th
birthday
I have verified that I am in fact “NOT” registered
I have not received a Status Information Letter in the past
I was born after December 31, 1959
I am claiming that I was exempt from the requirement to register
I was born male or I am transgender (born female)
SECTION 1 GENERAL INFORMATION
Last Name
First Name
Middle
List any other names used
Street Address (include apt. no.)
City
State
Zip Code
Social Security Number
Date of Birth
Daytime Telephone Number
Email Address
Student Financial Aid:
This request is for a status information letter related to the student financial aid process. The college’s
information is listed below.
Midlands Technical College
Post Office Box 2408
Columbia, SC 29202
Telephone Number: 803.738.7792
List each city and state (country if overseas) where you lived between your 18
th
and 26
th
birthdays:
______________________________________________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________
MIDLANDSTECH.EDU
i
PO Box 2408
i
Columbia, SC 29202
i
803.738.7792
SECTION 2 - MILITARY
If you served in the U.S. military, attach your proof of military service, such as a copy of your DD214, NGB Form 22, DD Form 4 (if
still on active duty), etc. If you attended a service academy or military school, provide a letter from the school or transcript
showing the dates.
To obtain proof of military service (DD Form 214, Official Military Personnel File), visit this website
(https://www.archives.gov/veterans/military-service-records).
Have you ever served in the U.S. military or attended a military service academy/school?
Yes (Please continue)
No (Skip to Section 3)
US Army
US Navy
Us Marine Corp
US Air Force
US Coast Guard
List dates of active duty service:
_______________________
to
__________________________
List dates of reserve duty service:
_______________________
to
__________________________
Did you attend a military service Academy?
The United States Military Academy (USMA)
The United States Naval Academy (USNA)
The United States Air Force Academy (USAFA)
The United States Coast Guard Academy (USCGA)
List dates of attendance:
_______________________
to
__________________________
Were you enrolled in an officer procurement program at a military school or university?
The Citadel
University of North Georgia
Norwich University
Virginia Military Institute
Texas A&M
University of Virginia Polytechnic and State University
List dates of attendance:
_______________________
to
__________________________
SECTION 3 INCARCERATED/ INSTITUTIONALIZED / HOSPITALIZED
Please attach poof if you were CONTINUOUSLY incarcerated, institutionalized, hospitalized or home confined for the entire period from your 18
th
through 26th birthdays. If you were released, escaped or otherwise out of custody for 30 days or more, you do not need to complete this form.
Call us at (888) 655-1825.
Were you continuously incarcerated, institutionalized, hospitalized, or home confined for the entire period of time between your 18
th
and 26
th
birthdays?
Yes (Please continue)
No (Skip to Section 4)
Incarcerated
Institutionalized
Hospitalized
Confined to Home
List dates during which you were incarcerated, institutionalized, hospitalized, or confined to home. For multiple dates, list
all. Attach proof of each instance.
to
to
to
MIDLANDSTECH.EDU
i
PO Box 2408
i
Columbia, SC 29202
i
803.738.7792
SECTION 4 - TRANSGENDER
The Military Service Act, including the requirement to register, applies to all individuals who were designated male at birth . If you were
born female and have transitioned to male, you must provide a copy of your female birth certificate (or medical documentation to show
that a transition has taken place) and legal documentation to show any changes to your name.
At birth gender was:
SECTION 5 US CITIZENSHIP AND IMMIGRATION
The Selective Service System does not share any information about an individual’s immigration status with outside agencies such as U.S. Immigration
and Customs Enforcement (ICE).
Are you a citizen of the United States by birth (born in the U.S., or overseas to qualifying U.S. parents)?
Yes (Skip to Section 6) No (Please continue)
Did you become a Naturalized Citizen more than 30 days before your 26
th
birthday?
Yes ________________________
Naturalization Date
(Skip to Section 6) No (Please continue)
Did you become a Permanent Resident (Green Card Holder) more than 30 days before your 26
th
birthday?
Yes ________________________
Resident Since Date
(Skip to Section 6) No (Please continue)
You must provide documentation to support your claim. Valid documentation includes that date of entry stamp in your passport or visa, I-94, or
I-20 with date of entry stamp, or any other official document that was accepted, stamped, or signed by USCIS and clearly s tates your arrival date.
If you submit the electronic version of the I-94, you must include the accompanying travel history. Please note, your Permanent Resident Card
(Green Card) cannot be used to document the date you arrived in the United States, even i f the date are the same.
Date you entered the United States for the first time:
Month/Day/Year
USCIS Status:
_____________________________________
Was the above date later than 30-days before your 26
th
birthday?
Yes, I was never in the United States (at any time, in any status) prior to this date. (Skip to section6)
No (Please continue)
Was the arrival date above earlier than your 18
th
birthday AND you left the county prior to your 18
th
birthday AND you did not
return to the United States (at any time in any status) until after the date that was 30 days before your 26
th
birthday?
Yes, I was never in the United States (at any time, in any status) between my 18
th
birthday and 30 days before my 26
th
birthday.
Date you entered the United States for the first time:
Month/Day/Year
USCIS Status:
_______________________________________
(Skip to Section 6)
No (Please continue)
For each period shown, you must provide documentation that shows you entered the United States as a valid non-immigrant and that you adhered
to the terms of your visa. For example, if you entered the United States as an international student and remained in that status until your 26
th
birthday, you would need to provide documentation indicating that you were admitted on an F-1 visa, attended school fulltime as required, and
either left the country or changed status when required. Acceptable documents may include copies of your I-20s, visa, and transcripts, or a letter
from the school stating the dates you attended there as a fulltime student. If OPT is authorized, the copy of the I-20 must reflect this. If you were on
an H-1 visa, you must provide documentation of your arrival/start date and a copy of the approved “Notice of Action”, an official company letter
showing your authorized dates of employment, or a W2 form showing you worked for the company that sponsored your visa.
The same applies for all non-immigrant statuses held. You must show your arrival/start date and documentation that shows you remained in good
status for the entire period. If you left the country, send a copy of the date stamp showing your arrival back into your country. If you remained in
the US and requested a changed of status, send a copy of the approved “Notice of Action” you received from USCIS.
You must include any times that you entered the United States illegally or without inspection, (no documentation is necessary). Likewise, you must
list any times when you violated the terms of your visa, overstayed your visa, or for any other reason became an undocumented immigrant.
You should provide as much information as possible. We will use the information you send to determine your registration status. For a list of
acceptable documents, please visit https://www.sss.gov/Portals/0/PDFs/DocumentationList.pdf.
Please list your immigration history showing all arrivals, departures and other changes in status, starting with the date of arrival that first put
you in the United States between your 18
th
and 26
th
birthdays and continuing until you were past your 26
th
birthday. Use a separate sheet if
necessary.
___________________________ __________________________ _________________________ ____________________________
Arrival/Start Date Good Until Date Departure/End Date USCIS Status
___________________________ __________________________ _________________________ ____________________________
Arrival/Start Date Good Until Date Departure/End Date USCIS Status
___________________________ __________________________ _________________________ ____________________________
Arrival/Start Date Good Until Date Departure/End Date USCIS Status
SECTION 6: REASON FOR FAILURE TO REGISTER BEFORE AGE 26
Provide a written explanation for not registering with the Selective Service System. If you believe you did register, please provide a detailed explanation
in the space provided below stating when, where, and how you registered. Include all addresses you may have used at that time.
_____________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________
SECTION 7: YOUR SIGNATURE
Sign and date, then send this letter, together with copies of ALL supporting documents showing proof of your
claim. You may include any other supporting information you would like us to consider. IMPORTANT: Do not send
original documents. The Selective Service may not return original documents. You should retain a copy of all
documents and correspondence submitted.
Selective Service System
Attention: SIL
PO Box 94638
Palantine, IL 60094-4638
Signature Date
No action can be taken until you receive a response from Selective Service. You must bring the response to the
Student Financial Services Office. You should retain a copy of all documents and correspondence submitted to us. You
will be notified by mail when your eligibility status has been determined.
MIDLANDSTECH.EDU
i
PO Box 2408
i
Columbia, SC 29202
i
803.738.7792
click to sign
signature
click to edit
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