83-950-2
                                                                             BOT 06-28-07

                                STATEMENTS AND CERTIFICATIONS 

All of the information on this Electronic Student Aid Report is true and complete to the 
best of my knowledge. If I am asked, I agree to give proof that my information is correct. 
This proof might include a copy of the previous years U.S. Income Tax Form filed by me 
or my family. I understand that if I purposely give false or misleading information on this 
Electronic Student Aid Report, I may be subject to a $20,000.00 fine, a prison sentence, 
or both. 

CERTIFICATION STATEMENT ON REFUNDS AND DEFAULT 

I certify that I do not owe a refund on any grant or loan, an not in default on any loan, or 
have made satisfactory arrangements to repay any defaulted loan, and have not borrowed 
in excess of the loan limits, under Title IV programs, at any institution. 

STATEMENT OF EDUCATION PURPOSE 

I will use all Title IV money receive only for expenses related to study at: Oglala Lakota 
College

Everyone whose information is given on this form should sign below. The student (and at 
least on parent, if Parental information is given), must sign below or this form will be 
returned unprocessed. 

Student                                                                           Date 

Spouse                                                                            Date

Parent                                                                            Date