Financial Aid Office
1200 16th Street
Golden CO 80401
303-384-2252 fax
Identity and Statement of Educational Purpose
(To Be Signed With Notary)

If the student is unable to appear in person at ______Colorado School of Mines_____
(Name of Postsecondary Educational Institution)
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
(Print Student’s Name)
Statement of 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
_________________________________________ for 2016-2017.
(Name of Postsecondary Educational Institution)

_________________________________________ _______________
(Student’s Signature)


(Student’s Campus Wide ID#)

Notary’s Certificate of Acknowledgement
State of ________________________________________________________________________
City/County of ___________________________________________________________________
On_____________________, before me, ____________________________________________,

(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
(seal) ________________________________________
(Notary signature)
My commission expires on _________________________