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_______________________________
Student’s ID Number
The Illinois Student Assistance Commission (ISAC) requires independent students to verify Illinois
residency.
For an independent student to be considered a resident of Illinois they must have physically resided in Illinois
for 12 continuous full months immediately prior to the start of the academic year for which assistance is
requested and Illinois must be their true, fixed, and permanent home.
You must submit a copy of one of the acceptable documents listed below with a date of issuance
between September 1, 2022 and September 1, 2023.
Acceptable Documents:
▪ Illinois auto registration
▪ Residential lease signed by you and your
landlord
▪ Illinois driver’s license or Illinois State Issued ID
▪ Utility or rent bills in your name
▪ Statement of benefit history from Illinois
Department of Public Aid
I have not lived in Illinois for one year
I did live in Illinois during this period;
however I am unable to provide supporting
documentation. I understand that checking
this box will render me ineligible to receive
the Illinois MAP Grant.
B. Identity and Statement of Educational Purpose
The student must appear in person at Illinois Valley Community 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:
2024-2025
Verification Worksheet
V4 - Independent Student
______________________________________________________________
Name
A. Illinois Residency Verification
(04/24)
815 North Orland Smith Rd, CTC-101S Oglesby, Illinois 61348 | E-mail: [email protected] |Telephone:
815-224-0438 |Fax: 815-224-0638
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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 Illinois Valley Community College for 2024-2025.
If the student is unable to appear in person at Illinois Valley Community 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
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)
Certification and Signature
The person signing below certifies that all the information reported
on this worksheet 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.
(04/24)
_____________________________________________________________________________
Student Signature →Must be drawn and not typed.
________________________
Date
_____________________________________________________________________________
Student Signature →Must be drawn and not typed.
________________________
Date
Forms can be submitted by
:
Fax:
815-224-0638 | Mail: Office of Financial Aid, 815 N. Orlando Smith Rd Oglesby, IL 61348 | In Person: CTC-101S
Note: Documents submitted via email cannot be accepted due to security reasons.
