CERTIFICATION



Applicant’s Name:

Address:

Social Security Number:



|. | | understand that the Virgin Islands Academic and Cultural Awards Endowment (the “Endowment”)



and the University of the Virgin Islands (the “University”) will rely upon the information contained in this certification for

purposes of establishing my residency and as justification for my application for funding, as a condition to awarding me financial

assistance. | hereby authorize the Endowment and the University to verify the information | have provided. | agree to notify the

proper officials at both the University and the Endowment of any changes in the information provided.



ll. thereby certify that | am a U.S. Citizen, or permanent resident alien, and | have been a resident of the United States Virgin

Islands and have so resided therein for a minimum of ten (10) years. | further certify that | have resided in the United States

Virgin Islands for at least five (5) years immediately preceding the submission of my application for funding from the

Endowment. | certify that the information is true and correct as of the date of submission of my application for funding from

the Endowment.



Ill. | certify that my application for funding from the Endowment is submitted based on:



| my significant contribution to the Virgin Islands through government service or otherwise.



[If Applicant has selected this box, please explain further below]



[financial need in order to pursue a professional, graduate or other studies or research or to engage in a cultural

project. [If Applicant has selected this box, please explain further below]



Explanation Of SECtION III: ........cccccccsscssssssssssscescsecsesssscsscsssscsscascessssssscessessaecaesesseusesseassecascaesee cessesacassecuecaesaesssassaeates



IV. | certify that the information contained in my application is complete

and correct and | understand that the submission of false information is grounds for rejection of my application, withdrawal of

any offer of funding, cancellation of funding, or appropriate legal action.



Dated:



APPLICANT:



Witness



Witness



SUBSCRIBED AND SWORN TO

BEFORE ME THIS DAY OF , 20 by ,

known to me or satisfactorily proven by presentation of identification in the form of



NOTARY PUBLIC



APPENDIX B

[BOARD APPROVED 10/28/08]