2017-18 Citizenship Affidavit Certification Form

(must be filled out in the presence of a notary)

CERTIFICATION OF TRUE, EXACT, AND COMPLETE COPY OF THE ORIGINAL DOCUMENTS

I certify that I,	(Print student's full name)
am the individual signing this statement, and I am providing a copy of my documents along with a copy of an unexpired valid government-issued photo identification (ID) such as, but not limited to, a driver's license, other state-issued ID, or passport that bears my portrait (or likeness).

List of document(s):

NAME OF VALID PHOTO ID	EXPIRATION DATE OF VALID PHOTO ID	ISSUING AUTHORITY OF VALID PHOTO ID

 

NAME OF CITIZENSHIP AND/OR IMMIGRATION DOCUMENT(S)	EXPIRATION DATE (IF ANY) OF CITIZENSHIP AND/OR IMMIGRATION DOCUMENT(S)

ONE STOP FOR STUDENT SERVICESS-SFA-VER-CITC
P.O. Box 5190, Kent, OH 44242 ♦ Phone: 330-672-6000 ♦ Fax: 330-672-6001 ♦ Email: onestop@kent.edu

I understand that providing false or misleading information or documents is punishable by fine or imprisonment and may make me liable for repayment of any funds received on the basis of the information and documents I have provided.

Student Signature

KSU ID

Date

Notary's Certificate of Acknowledgement

State of
City/County of
On	(Date)	before me	(Notary's name)

Personlly appeared	(Printed name of signer)		and proved to me
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		(Notary signature)
My commission expires on		(Date)