Parkland College ensures equal educational opportunities are offered to all students regardless of race, color, national origin, gender, disability, sexual orientation, veteran/Vietnam veteran era, age, or
religion, and is Section 504/ADA compliant. For additional information or accommodations call 217-351-2505.
Page 1 of 3 (07/24)
2024-2025
Verification Worksheet
V4 - Dependent Student
Forms can be submitted by mail, fax (217/373-3807), or delivered in person.
To ensure your privacy, DO NOT submit forms through email.
____________________________________________________________ ____________________________
Name Student’s ID Number
To complete the Identity and Statement of Educational Purpose,
please fill out either Section A or Section B (only one section needs to
be completed to fulfil requirements).
A. Identity and Statement of Educational Purpose
(Must Be Signed at the Institution)
The student
must appear in person at Parkland College to verify their identity by presenting a valid,
unexpired, 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:
Identity and Statement of Educational Purpose (To Be Signed With Notary)
Statement of Educational Purpose
I certify that I, _____________________________, am the individual signing this Statement of Educational
(Print Student Name)
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 Parkland College for 2024-2025.
_____________________________________________ ________________
(Student’s Signature) (Date)
Office of Financial Aid and Veteran Services
2400 W. Bradley Avenue, U‐286
Champaign, IL 61821‐1899
E‐mail: finai[email protected]
Telephone: 217‐351‐2222
Fax: 217-373-3807
Parkland College ensures equal educational opportunities are offered to all students regardless of race, color, national origin, gender, disability, sexual orientation, veteran/Vietnam veteran era, age, or
religion, and is Section 504/ADA compliant. For additional information or accommodations call 217-351-2505.
Page 2 of 3 (07/24)
B. Identity and Statement of Educational Purpose
(Must Be Signed in the Presence of a Notary)
If the student is unable to appear in person at Parkland College to verify their identity, the student must
provide:
(a) A copy of the valid, unexpired, 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.
Notary’s Certificate of Acknowledgement
State of Illinois
City/County of __________________
On____________ (Date), before me, ____________________________ (Notary’s name), personally
appeared, ____________________________ (Printed name of signer), and proved to me on basis of
satisfactory evidence of identification_________________________ (Type of government-issued photo ID)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
__________________ __________
(Notary signature) (Date)
Parkland College ensures equal educational opportunities are offered to all students regardless of race, color, national origin, gender, disability, sexual orientation, veteran/Vietnam veteran era, age, or
religion, and is Section 504/ADA compliant. For additional information or accommodations call 217-351-2505.
Page 3 of 3 (07/24)
Illinois Residency Verification
The Illinois Student Assistance Commission (ISAC) requires students to verify Illinois residency.
For a dependent student to be considered an Illinois resident, his/her parent from the 2024-25 Free
Application for Federal Student Aid (FAFSA) must physically reside in Illinois and Illinois must be
his/her true, fixed, and permanent home.
You must submit a copy of one of the acceptable documents listed below.
• Parent’s Illinois driver's license or Valid State of Illinois Identification Card issued prior to
8/19/2023
• Utility or rent bills in the parent’s name issued between 8/19/2022 and 8/19/2023
• Illinois Auto Registration for the parent issued between 8/19/2023 and 8/19/2024
• Parent’s Statement of benefits history from the Illinois Department of Healthcare and Family
Services, Illinois Department of Employment Security, or Social Security Administration issued
between 8/19/2022 and 8/19/2023
• Parent’s residential lease issued between 8/19/2022 and 8/19/2023
• Parent’s Illinois voter’s registration card issued between 8/19/2022 and 8/19/2023
• Parent’s property tax bill issued between 8/19/2022 and 8/19/2023
If documents cannot be provided, please check the box below:
My parent is unable to provide any of the required documents to verify Illinois residency. I
understand that checking this box will render me ineligible to receive the Illinois MAP Grant.
Certification and Signatures
I certify that all the information reported on this form is complete and correct. The
student and one parent whose information was reported on the FAFSA must sign and
date.
________________________________ ______________
Student Signature Date
________________________________ ______________
Parent Signature Date
WARNING: If you purposely give
false or misleading information on
this worksheet, you may be fined, be
sentenced to jail, or both.
Handwritten signatures are required.
Electronic signatures will not be
accepted.
