2015-2016 Identity/Statement of Educational Purpose Worksheet Independent Student Your 2015–2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm the information you and your spouse (if applicable) reported on your FAFSA. To verify that you provided correct information, the Student Financial Services (SFS) Office staff will compare your FAFSA with the information on this worksheet and with any other required documents. If there are differences, your FAFSA information may need to be corrected. You must complete and sign this worksheet, attach any required documents, and submit the form and other required documents to the SFS Office. Clarion may ask for additional information. A. Independent Student’s Information ______________________________________________________________ Student’s Last Name Student’s First Name Student’s M.I. ___________________________________ Student’s Clarion ID Number ______________________________________________________________ Student’s Street Address (include apt. no.) ___________________________________ Student’s Date of Birth ______________________________________________________________ City State Zip Code ___________________________________ Student’s Alternate or Cell Phone Number ______________________________________________________________ Student’s Home Phone Number (include area code) B. Independent Student’s Information to Be Verified 1. Complete this section if someone in your household (see household definition below) received benefits from the Supplemental Nutrition Assistance Program or SNAP (formerly known as food stamps) any time during the 2013 or 2014 calendar years. SNAP may be known by another name in some states. For assistance in determining the name used in a state, please call 1800-4FED-AID (1-800-433-3243). The student’s household includes:  The student.  The student’s spouse, if the student is married.  The student’s or spouse’s children if the student or spouse will provide more than half of their support from July 1, 2015, through June 30, 2016, even if the children do not live with the student.  Other people if they now live with the student and the student or spouse provides more than half of their support and will continue to provide more than half of their support through June 30, 2016. Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we may require documentation from the agency that issued the SNAP benefits in 2013 or 2014. One of the persons in my household, Family Member Name: _____________________, Family Member Relationship to me: ___________________________, received SNAP benefits in 2013 or 2014. If asked by my school, I will provide documentation of the receipt of SNAP benefits during 2013 and/or 2014. V4 2. Complete this section if you or your spouse, if married, paid child support in 2014. Either I, or if married my spouse, paid child support in 2014. I have indicated below the name of the person who paid the child support, the name of the person to whom the child support was paid, the names of the children for whom child support was paid, and the total annual amount of child support that was paid in 2014 for each child. If asked by my school, I will provide documentation of the payment of child support. If you need more space, attach a separate page that includes your name and Clarion ID at the top. Name of Person Who Paid Child Support Name of Person to Whom Child Support was Paid Name and Age of Child for Whom Support Was Paid Marty Jones(example) Chris Smith Terry Jones (Age 15) Amount of Child Support Paid in 2014 $6,000.00 3. Identity and Statement of Educational Purpose **To Be Signed at Clarion University: The student must appear in person at Clarion 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. The institution 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 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 Clarion University for 2015-2016. _________________________________________ (Student’s Signature) _______________ (Date) ______________________ (Student’s ID Number) OR V4 Student’s Name: ______________________________________________ Clarion ID: ______________________ **To Be Signed With Notary (if the student is unable to appear in person at Clarion University to verify his or her identity) The student must provide: (a) A copy of the valid government-issued photo identification (ID) that is acknowledged in the notary statement below, 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. 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 Clarion University for 2015-2016. _________________________________________ (Student’s Signature) _______________ (Date) ______________________ (Student’s ID Number) Notary’s Certificate of Acknowledgement State of __________________________________________________________________________________________ City/County of ____________________________________________________________________________________ On________________________, before me, ____________________________________________________________, (Date) (Notary’s name) personally appeared, ____________________________________________, and provided to me on basis of satisfactory (Printed name of signer) evidence of identification _______________________________________ to be the above-named person who signed the (Type of government-issued photo ID provided) foregoing instrument. WITNESS my hand and official seal (seal) ________________________________________ (Notary signature) My commission expires on __________________ OVER V4 C. Certification and Signature Each person signing below certifies that all the Information reported is complete and correct. WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. _________________________________________________ Student’s Signature _________________________________ Date _________________________________________________ Spouse’s Signature (if student is married) _________________________________ Date Do not mail this worksheet to the U.S. Department of Education. Submit this worksheet to: Student Financial Services Office B-16 Carrier Hall Clarion University of Pennsylvania Clarion, PA 16214 (You should make a copy of this worksheet for your records.) V4