2010-2011
RETURN TO:
Name of Financial Aid Applicant (Please print)
Last First Middle
Student ID Number: ___________________________________________
2009 STUDENT’S (SPOUSE) INCOME CERTIFICATION
Attached is a signed photocopy of my/our 2009 federal
income tax return, including all schedules and
attachments.
I/We did not file, and are not required to file, a 2009
federal income tax return.
List below all of the sources and amounts of money received from January 1, 2009 through December 31, 2009. Include
untaxed income (e.g., AFDC/TANF/CalWORKs, SSI, Military Living Allowance, disability) and earnings or income not
reported on a federal or state income tax return (e.g., unemployment insurance income if a tax return was not filed).
Source of Money
Annual Amount
January 2009 – December 2009
$
$
$
Total
$
If you claim to be a self-supporting student and if your income was not sufficient to pay rent, food, and other expenses,
explain how your expenses were met: (You may attach a separate sheet if additional space is needed.)
I/We hereby certify that all information reported on this form and any attachments hereto is true, complete, and accurate.
False statements or misrepresentation will be cause for denial, reduction, withdrawal, and/or repayment of financial aid.
Signatures are required for all persons reporting income above.
Signature of Applicant Date
Signature of Applicant’s Spouse Date
ame of Applicant’s Spouse (Please print)
California Information Privacy Act
State and federal laws protect an individual’s right to privacy 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 from 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. If 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 of the college to which you are applying.
Cerritos College
Financial Aid Office
11110 Alondra Blvd.
Norwalk, CA 90650
210/SSIC (Rev. 01/14/10, rlq)
