___________________________________________ _______________________________________
Office of Financial Aid
Waycross Campus (912) 287-6584
Jesup (912) 427-5800
Alma (912) 632-0951
Camden (912) 510-3327
Hazlehurst (912) 379-0041
Baxley (912) 367-1700
Golden Isles (912) 262-4999
Website: www.coastalpines.edu
Identity Verification
and Statement of
Educational
Purpose
Form: IVEP21
Aid Year: 2020-2021
Please T
ype or Print clearly.
Student Information
_____________________________ _______________________ ____________________________
Last Name First Name & Middle Initial CPTC – Student ID Number
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE
(Completion of this section MUST BE WITNESSED AND SIGNED BY A NOTARY OF THE PUBLIC)
If the student is unable to appear in person at Coastal Pines Technical College
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, and 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
(Print Student’s Name)
Statement of 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 Coastal Pines Technical College for 2020-
2021.
Student’s Signature Date
Notary’s Certificate of Acknowledgement
State of _________________________________________________________________________________
City/County of ___________________________________________________________________________
On ____________________, before me, _________________________________________________
(Date) (Notary’s Name)
Personally appeared, _______________________________________________, and provided to me on the
(Printed Name of signer)
Basis of satisfactory evidence of identification __________________________________________________
Type of government-issued photo ID provided)
To the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal _______________________________________________
(Notary Signature)
My commission expires on _________________________________________
(Date)
(SEAL)
This document must be “Hand Delivered” or delivered by U.S. Postal Service to
your local
CPTC Office of Financial Aid.
As set forth in the student catalog, Coastal Pines Technical College (CPTC) does not discriminate on the basis of race, color, creed, national or
ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in
those special circumstances permitted or mandated by law). The following persons have been designated to coordinate the College’s
implementation of non-discrimination policies: Katrina Howard, Title IX Coordinator, Jesup Campus, Office 132, khoward@coastalpines.edu
,
912.427.5876; Cynthia Linder, Office 1439, Title IX Coordinator, Waycross Campus, clinder@coastalpines.edu , 912.287.4098; and Cathy
Montgomery, ADA/Section 504 Coordinator, Golden Isles Campus, Office 1141, cmontgomery@coastalpines.edu , 912.262.9995.
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