SAGE ID:
Name:
Student Financial Services
2015-2016 Identity and Statement of Educational Purpose
(To Be Signed at the Institution)
The student must appear in person at Brandeis University to verify his or her identity by presenting a
valid, government-issued photo identification (ID), such as, but not limited to, a driver’s license, other
state-issued ID, or passport. Brandeis University will maintain a copy of the student’s photo ID that is
annotated by the institution with the date it was received and reviewed and the name of the official at the
institution authorized to collect the student’s ID.
In addition, the student must sign, in the presence of the institutional official, the following statement:
Statement of Educational Purpose
I certify that I ______________________________________ am the individual signing this Statement of
(print full name clearly)
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 Brandeis University for 2015–2016.
_________________________________________
Student signature
_______________
Date
__________________________________________
Student ID Number
For Internal Use Only:
Photo ID Attached:
□ Driver’s License
□ Passport
□ Valid Government Issued ID
□ Military ID
Exp. Date: __________
SFS Employee Name (Please Print): _____________________________ Date: _________________________
SFS Employee Title: _______________________ SFS Employee Signature: __________________________
415 South Street Waltham, MA 02453
781-736-3700 fax 781-736-3719 www.brandeis.edu
SAGE ID:
Name:
***TO BE COMPLETED BY A NOTARY:
State of ______________________________________________________________________________
City/County of ________________________________________________________________________
On____________________, before me, ____________________________________________________
(Date)
(Notary’s Name)
Personally appeared ___________________________________________________, and provided 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.
Witness my hand and official seal ____________________________
(Official Seal or Stamp)
(Notary signature)
My commission expires on ________________________________
(Date)
415 South Street Waltham, MA 02453
781-736-3700 fax 781-736-3719 www.brandeis.edu