STATEMENT OF EDUCATIONAL PURPOSE 2015-16
(Instructions on Completion Included)
By signing this document, I certify that I am the individual signing this Statement of Educational Purpose and that the
federal assistance I may receive will only be used for educational purposes and to pay for the cost of attending Doane
College for the 2015-2016 academic year.
______________________________________
Print Name:
_________________________________________
SSN:
_______________________________________
Signature:
_________________________________________
Date:
TO BE COMPLETED BY DOANE COLLEGE OFFICIAL (if witnessed in person by school official):
On this day of _____day of _____, 20___,
___________________________________
_________________________________
Doane College Authorized Signature
Title and Department
___________________________________________
Printed Name of Authorized Signature
Provided a Government Issued Photo Identification and photocopy made:
Y/N
Photo Copy of valid Government Issued Photo Identification has been dated, initialed, and attached by Doane official: Y / N
Type of Identification Produced _________________________________________________
OR
CERTIFICATE OF ACKNOWLEDGEMENT BY NOTARY (if statement and identity are not presented to Doane official)
STATE OF: ____________________________________
CITY/COUNTY OF _______________________________
On this________ day of ________________________, 20_____, before me: _______________________________,
(date)
(month)
(notary)
personally appeared, _______________________________________________________, and provided to me on basis
(signer)
of satisfactory evidence of identification to be the above-named person who signed the foregoing instrument.
Type of Identification Produced: _______________________________________________. (attach copy)
W ITNESS my hand and official
Signature
NOTARY STAMP OR SEAL
My Commission Expires on: ________________________
(Date)