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.

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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
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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

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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.)

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