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Sam Houston State University Financial Aid and Scholarships Office

The document is a selective service statement form for a student to fill out regarding their selective service registration status. It provides instructions on how to register for selective service and what documentation is required for different registration statuses. It also warns that knowingly providing false information can result in fines or jail time.

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Steven Andrew
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47 views

Sam Houston State University Financial Aid and Scholarships Office

The document is a selective service statement form for a student to fill out regarding their selective service registration status. It provides instructions on how to register for selective service and what documentation is required for different registration statuses. It also warns that knowingly providing false information can result in fines or jail time.

Uploaded by

Steven Andrew
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Sam Houston State University

Financial Aid and Scholarships Office


MEMBER THE TEXAS STATE UNIVERSITY SYSTEM

SELECTIVE SERVICE STATEMENT 2021-2022


If you make any corrections, white outs, or alterations to any of your information on this form, you MUST initial next to it.

Student Name (blue or black ink only): ___________________________________________________


Nipuna Indula Wanninayake Mudiyanselage SAM ID: ____________________________
000889298

Are you currently registered for Selective Service, as required by federal law (34 CFR 668.37)?
Please select one of the following and sign below:
Selective Service Status Required Documentation
 Registration Acknowledgement documentation OR
□ I am registered  Online verification from www.sss.gov OR
 Other: _____________________________
 You are female by birth, and must update question #21 on FAFSA at www.fafsa.gov and
resubmit. This form is not needed. OR
□ I am exempt
 Signed statement explaining reason for exemption AND if exemption is anything other than being
under the age of 18, provide documentation proving exemption
All male U.S. Citizens, regardless of where they live, and male immigrants, whether documented or
□ I am not registered undocumented, residing in the United States, who are age 18 through 25, are required to register with
Selective Service.
You are not eligible for How to register?
federal or state aid unless  Register online at www.sss.gov with valid social security number.
you select an option above  Check box on FAFSA: A male can check “Register Me” on Box #22 of the application, and the
and provide supporting Department of Education will furnish Selective Service with the information to register him.
documentation.  At the Post Office: Selective Service mail-back registration forms are available at any U.S. Post
Office. A male can fill it out, sign and date, affix postage, and mail to Selective Service without
the involvement of the postal clerk. Men living overseas may register at any U.S. Embassy or
consular office.

I, ______________________________,
Nipuna Indula Mudiyanselage hereby certify that the selective service status provided is true and correct.
I understand that I must provide documentation if requested by my institution that I may be required to complete a
new statement for each academic year for continued eligibility.

WARNING: If you purposely give false or misleading information you may be fined, sentenced to jail, or both. Each person signing below certifies that all of the information
is complete and correct.

Forms must be
signed.
Student Signature: __________________________________________________________________ Date: _________________________
06/21/2021
Electronic
signatures will Parent Signature: ___________________________________________________________________ Date: _________________________
not be
accepted. 
Return completed form to: Financial Aid and Scholarships Office
Email: PDF from SHSU Email to [email protected] • Fax: 936.294.3668 • Mail: Box 2328, Huntsville TX 77341-2328

RRAAREQ Code: SSST22 Revised 11/2020

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