Fillable Form Dep - V5 - Dependent Verification Worksheet (Page 3 of 3) in pdf

Part 6. Documentation of Identity & Statement of Purpose

How will you submit this form?

In-person ______

If “in-person” follow directions in Box A

By mail

______

If “by mail” follow directions in Box B

BOX A

: Complete 1 and 2 below and submit this form in-person. Bring your government issued photo ID with you.

1. Attach a clear, readable copy of the student’s government issued photo ID. (Driver’s license, passport, military ID, etc.)

Copy of photo ID is attached: YES _____

NO _____ If “no” verification is incomplete and you will not be awarded financial aid.

2. Read and sign the following statement of purpose.

I certify that I ________________________________ am the individual signing this 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 San Juan College for 2016-2017.

Student Signature: _____________________________ Date: ___________

BOX B

: If you are unable to appear in person at SJC complete and sign this form in the presence of a Notary Public. Mail the

original form with Notary’s signature and seal or stamp to the SJC Financial Aid Office.

1. Attach a clear, readable copy of the student’s government issued photo ID. (Driver’s license, passport, military ID, etc.)

Copy of photo ID is attached: YES _____

NO _____ If “no” verification is incomplete and you will not be awarded financial aid.

2. Read and sign the following statement of purpose in front of a Notary.

I certify that I ________________________________ am the individual signing this 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 San Juan College for 2016-2017.

Student Signature: _____________________________ Date: ___________

In the State of ________________ and city/county of ___________________ on (date) ______________, before me (Notary’s

name) _____________________________ personally appeared (student name) ___________________________________ and

provided me on basis of satisfactory evidence identification (type of gov’t issued photo ID) __________________________ to

be the above named person who signed the foregoing instrument.

Witness my hand and official seal:

Notary Signature: ______________________________ Date: ___________

My commission expires on this date: _______________________________

YOU MUST SUBMIT THIS FORM IN-PERSON OR BY MAIL WITHIN TWO WEEKS. E-MAIL AND FAXES WILL NOT BE ACCEPTED.

By signing this worksheet, I (we) certify that all the information reported on this worksheet is complete and accurate. (At least one

parent must also sign.) Warning: If you purposely give false or misleading information on this worksheet, you may be fined,

sentenced to jail, or both.

______________________________

___________

______________________________

__________

Student Signature

Date

Parent Signature

Date

Name of Financial Aid Staff Member: ___________________________

Signature of Financial Aid Staff Member: ___________________________

Date received all documents: ___________________________

Ph. 505-566-3323 Fax: 505-566-3593 E-mail:

financialaid@sanjuancollege.edu

Address: San Juan College, Financial Aid Office, 4601 College Blvd, Farmington, NM 87402

Form Dep - V5 - Dependent Verification Worksheet Page 3

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