2010-2011
210/PIC (Rev. 01/14/10, rlq)
ame of Financial Aid Applicant (Please print)
RETURN TO:
N
ast First Middle
Student ID Number: __________________________________________
L
2009 PARENTS’ INCOME CERTIFICATION
Cerritos College
Financial Aid Office
11110 Alondra Blvd.
Norwalk, CA 90650
federal
turn, including all schedules and
attachments.
ot required to file, a 2009
federal income tax return.
Attached is a signed photocopy of my/our 2009
income tax re
I/We did not file, and are n
List below all of the sources and amounts of money received from January 1, 2009 through December 31, 2009. Include
untaxed income (e.g., CalWORKs, SSI, Military Living Allowance, disability income) and earnings or income not reported
on a federal or state income tax return (e.g., unemployment insurance income if tax return not filed).
Source of Money
Annual Amount
January 2009 – December 2009
$
$
$
Total
$
Explain special circumstances (if any) concerning your financial situation (you may attach a separate sheet if additional
pace is needed): s
I/We hereby certify that all information reported on this form and any attachments hereto is true, complete, and accurate.
tion, withdrawal, and/or repayment of financial aid.
ignatures are required for all persons reporting income above.
False statements or misrepresentation will be cause for denial, reduc
S
Signature of Father Date
ame (Please print)
Signature of Mother Date
ame (Please print)
California Information Privacy Act
State and federal laws protect an individual’s right to
rivacy regarding information pertaining to oneself. The California Information Practices Act of 1977 requires the
following information be provided to financial aid applicants who are asked to supply information about themselves. The principal purpose for requesting information on this
form is to determine your eligibility for financial aid. The Chancellor’s Office policy and the policy of the community college to which you are applying for aid authorize
maintenance of this information. Failure to provide such information will delay and may even prevent your receipt of financial assistance.
This form’s information may be transmitted to other state agencies and the federal government if required by law. Individuals have the right of access to records established fro
information furnished on this form as it pertains to them. The officials responsible for maintaining the information contained on this form are the financial aid administrators at
the institutions to which you are applying for financial aid. The SSN may be used to verify your identity under record keeping systems established prior to January 1, 1975. I
your college requires you to provide an SSN and you have questions, you should ask the financial aid officer at your college for further information. The Chancellor’s Office and
the California community colleges, in compliance with federal and state laws, do not discriminate on the basis of race, religion, color, national origin, gender, age, disability,
medical condition, sexual orientation, domestic partnership or any other legally protected basis. Inquiries regarding these policies may be directed to the financial aid office o
hich you are applying.
the college to w
