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Verification+of + Identity+ and+S tatement+ of+ Educational+ Purpose+
!"
#$%&'($ )*(+,-.!$*,()
Last+ Name+ First+ Name+ M.I.+ UH+I D +Number/Username +
Phone+ Number+ Date+ of+ Birth+
/"
&'($*$0) !(&) $!$'.'($), +) &%1!$*,(!2) %-3,#')
4$, )/' )#*5('& )6*$7 )(,$!- 0 8)9 : );<= )>?@ )A<B )>CD@) B<) E=CF9B) BG@) H<I=F@AB) 9A) J@?E<AK)
* # ' 3
Instructions +for +comp le tin g +in- person+a t+ postsecondary+ educational+ institutional:+
1. Please+ present+ an +unexpired +valid +government-issued +photo +identification +(ID),+ such +as+ but+ not+ limited +to +a +driver's+ license,+ other+
state-issued +ID,+ or +passport +to +the +financial+a id +office. +
Instructions +for +comp le tin g +with +No t ary , if+n ot +able +to +g o +in-person:+
1. A+c opy+ of+ the+ unexpired+v alid+g overnment-issu e d +pho to +ide nt ifica tio n +(ID) +that +is +acknow led g e d +in +the +notary +statem e n t +below,+ such +as+
but+ not+ limited+t o+a + driver’s+ license,+ other+ state-issued +ID,+ or +p a ss po r t;+a nd +
2. The+ original+ Statement+ of+ Educational+ Purpose+ provided +below,+ which +must+ be+ notarized.+
3. The+ original+ document+ must+ be+ mailed/given +to +the+ Financial+ Aid +Office.+ +>L@H )<?) @F>9D@H) M@?E9<AE) N9DD) A<B) C@)>II@JB@H. +
#$!$'.'($) ,+ '&%1!$*,(!2 3%-3,#' 4.=EB C@ E9OA@H 9APJ@?E<AK
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 at
tending for _+ academic year.
(Name+ of+ Postsecondary Educational Institution) (Ex.+ 2020 - 2021+ academic year)
Signature Date UH+ ID Num
ber
(,$!-0Q#) 1'-$*+*1!$') ,+) !1R(,62'&5'.'($
State of City/County of
On ,+be
fore me,
(Date) (Notary’s+ name)
personally appeared, ,+and +proved +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.
6*$('## F; G
>AH >AH <::9I9>D E@>D
(Notary’s+ Signature)
(Seal) My commission expires on
Date
-'$%-( $7*# +,-. !2,(5 6*$7 !(0 ,$7'-) -'S%*-'& &,1%.'($!$*,() $,) $7' 1,..%(*$0 1,22'5' 1!.3%# $7!$ 0,%) 6*22 /' !$$'(&*(5T
Hawaiʻi Community College
1175+ Manono Street *+ Hilo, HI 96720
Honolulu Community College
874+ Dillingham Boulevard *+ Honolulu, HI 96817
Kapiʻolani Community College
4303+ Diamond Head Road *+ Honolulu, HI 96816
3-1901+ Kaumualiʻi Highway *+ Lihuʻe, HI 96766
Leeward Community College
96-045+ Ala+ Ike+ Street *+ Pearl City, HI 96782
University of Hawaiʻi Maui College
310+ West Kaʻahumanu Ave+ *+ Kahului, HI 96732
Windward Community College
45-720+ Keaʻahala+ Road *+ Kāneʻohe, HI 96744
The University is committed+ to+ a+ policy of nondiscrimination+ on+ the basis of race, sex, gender identity+ an d expression, age, religion, color, national origin, ancestry, citizenship, disability,
genetic+ information, marital status, breastfeeding, income+ assignment for child support, arrest and court record (except as+ permissible+ under State law), sexual+ orientation, national+ guard
absence, or status+ as+ a+ covered veteran.
UH Title+ IX+ Coordinators' names+ and contact information are+ available+ at: https://www.hawaii.edu/titleix/help/coordinator/+ and UH 504+
Coordinators’ names and+ c
ontact information+ are available at: https://www.hawaii.edu/offices/eeo/ada-504-coordinators/
FAO USE ONLY
Documents rev
iewed: FAO Signature:
Rev. 10/2019
click to sign
signature
click to edit
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