Institutional Student Information Record Certification Form printable pdf download

Institutional Student Information Record Certification Form

Institutional Student Information Record

Certification Form

Student’s Name _________________________________________

Student’s Social Security # _____-_____-_______

Read, Sign, and Date

If you are the student, by signing this application you certify that you (1) will use federal and/or state

student financial aid only to pay the cost of attending an institution of higher education, (2) are not in

default on a federal student loan or have made satisfactory arrangements to repay it, (3) do not owe

money back on a federal student grant or have made satisfactory arrangements to repay it, and (4) will

notify your school if you default on federal loans.

If you are the parent or the student, by signing this application you agree, if asked, to provide

information that will verify the accuracy of your completed form. This information may include your

U.S. or state income tax forms. Also, you certify that you understand that the Secretary of Education

has the authority to verify information reported on this application with the Internal Revenue Service

and other Federal agencies. If you purposely give false or misleading information, you may be fined

$20,000, sent to prison, or both.

Everyone whose information is given on this form should sign below. The student (and at least one

parent, if parent information is given) MUST sign below.

Student: _______________________________________________________

Date: ________

Parent: ________________________________________________________

Date: ________

Institutional Student Information Record Certification Form