Verification Of Identity And Statement Of Educational Purpose Form (Page 2 of 2) in pdf

2016‐17 Verification of Identity and

Mail

this form with a clear copy of the photo ID used to

verify your identification to:

Statement of Educational Purpose

MTSU, MT One Stop, SSAC Room 260, 1301 East Main

Street, Murfreesboro, TN 37132

(MUST Be Signed In the Presence of a Notary)

IS NOT

A faxed or emailed copy

acceptable.

(V4, V5 – ORIGINAL TO FINANCIAL AID) (IDEN17)

If the student is unable to appear in person at the Middle Tennessee State University’s MT One Stop to verify his or her

identity, the student must provide to the institution:

(a) A copy of the unexpired valid government‐issued photo identification (ID) that is acknowledged in the notary

statement below, or that is presented to a notary, such as, but not limited to a driver’s license, other state‐issued ID, or

passport; and

(b) The original notarized Statement of Educational Purpose provided below, which must be notarized. If the notary

statement appears on a separate page than the Statement of Educational Purpose, there must be a clear indication that

the Statement of Educational Purpose was the document notarized.

Identity and Statement of Educational Purpose

I certify that I _____________________________ am the individual signing this Statement of Educational Purpose and

(Print Student’s Name)

that the Federal student financial assistance I may receive will only be used for educational purposes and to pay the cost

of attending Middle Tennessee State University for 2016‐2017.

FINANCIAL AID OFFICE USE ONLY

FAA Access Reporting

_______________________________________ ______________

(Student’s Signature)

(Date)

__ 1. Verification completed in person, no issues

__2. Verification completed using notary, no issues

M_____________________

__ 3. Verification attempted, identity issues found

__ 4. Verification attempted, HS completion issue

(Student’s ID Number)

__ 5. No response from applicant or unable

to locate

Notary’s Certificate of Acknowledgement

Certified by:__________________________________

State of ________________________________________________

Date FAA Access Certified:______________________

City/County of ___________________________________________

On_____________________, before me, _________________________,

(Date)

(Notary’s name)

personally appeared, ____________________________________________, and provided to me basis of satisfactory

(Printed name of signer)

evidence of identification _______________________________________ to be the above‐named person who signed

(Type of government‐issued photo ID provided)

the foregoing instrument.

WITNESS my hand and official seal

(seal) ________________________________________

(Notary signature)

My commission expires on _________________________

(Date)

Verification Of Identity And Statement Of Educational Purpose Form Page 2

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