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Citizenship Clarification
Lakeland ID Number
_________________________________________________
Last Name
____________________________________________
First Name
We have completed the initial review of your Free Application for Federal Student Aid (FAFSA) and have determined that we need
additional information regarding your citizenship status. Please complete this form, attach the appropriate documentation, and return
it to the Financial Aid Office.
PROCESSING OF YOUR FINANCIAL AID CANNOT BE COMPLETED UNTIL THIS FORM AND ALL
REQUIRED DOCUMENTS ARE SUBMITTED TO THE FINANCIAL AID OFFICE
Please check the boxes that apply to you and attach copies of the requested documentation:
I am a U.S. Citizen.
[ ] ATTACHED is a legible copy of my U.S. Birth Certificate, Certification of Naturalization, Certificate of Citizenship,
Certification of Birth Abroad or U. S. Passport.
I am an eligible non-citizen.
[ ] ATTACHED is a legible copy (both sides) of one of the following:
(a)
(b)
(c)
(d)
Permanent Resident Card (I-551-since 1997);
Resident Alien Card (I-551-before 1997);
Alien Registration Receipt Card (I-151-prior to June 1978);
Conditional Green Card (I551C)
[ ] ATTACHED is a legible copy of my Arrival Departure Record (I-94) from the U.S. Department
of Homeland Security with any one of the following designations:
(a)
(b)
(c)
(d)
(e)
(f)
(g)
Refugee
Asylum Granted
Conditional Entrant (before April 1, 1980)
Parolee (I-94 confirms that you were paroled for a minimum of one year and status has not expired)
Cuban-Haitian Entrant
T-Visa holder
Holder of a valid certification or eligibility letter from the Department of Health and Human Services showing a
designation of Victim of Human Trafficking.
Statement of Certification: I certify that the information provided to document my citizenship status is true and complete.
__________________________________________
Student’s Signature
_________________________________________
Date
- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -FOR OFFICE USE ONLY - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - Form ______________________________
Sent to DHS _____ Y
_____ N
Approved _____ Y
_____ N
Date _____________________________
Approved _____ Y _____ N
Comments _______________________________________________________ Date _______________________________
Revised 4-1-2015