Revised 12/19/2017
V4/V5
Identity and Statement of Educational Purpose
To Be Signed With Notary
If the stud
ent is
unable to appear in person at Las Positas College Aid Office to
verify his/her identity, the student must provide:
a. a copy of the valid govern
ment-issued photo identification (ID), such as, but not limited to, a driver’s license, other state
issued ID, or passport, that is acknowledged in the notary statement below; and
b. the original notarized Statement of Educational Purpose provided below.
The institution must maintain the copy of the student’s photo ID and the original notarized statement that accompanies it.
Student Name : Date:
Address:
ID#:
City, State, Zip:
Statement of Educational Purpose
I certify that I, _____________________________, am the individua
l signing this Statement of Educational Purpose and that the
(Print S
tudent’s Name)
federal student financial assistance I may receive will only be used for educational purposes and to pay the cost of
attending /DV3RVLWDVCollege for 2019-2020.
Warning: If
you purposely give false or misleading
information
on this worksheet, you may be fined, be sentenced to jail, or both.
I hereby certify that the information I have provide is true and correct.
I have attached documentation as requiered above.
_______________________________
______
______
_______________________________________
Student’s Printed Name Student’s Signature Date Signed
Notary’s Certificate of Acknowledgement
State of ______________________________________ City/County of ____________________________________________
On (date) _____________________, before me, (notary’s name) ____________________________________________, personally
appeared (
printed name of signer)____________________________________________ and proved to me on the 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
____________________________________
(Notary signature)
My commission expires on _________________________
(Date)
For Financial Aid Office Use Only:
ID Number:
