2018-2019 Verification of Separation Status
This document needs to be completed by: Separated Student Separated Parent
You must sign this form in the presence of a notary.
The Financial Aid Staff may not provide notarization.
Student’s Full Name: GTCC ID:
I, (print your full name) , am separated from my
spouse, (print spouses full name) , as of .
We are no longer residing together and plan to obtain a divorce.
My address is: Street Apt
City State Zip
My spouses address is: Street Apt
City State Zip
NOTE: You must submit a letter on letterhead from one of the following persons or organizations:
For military and their dependents: A letter is required from the Family Services Office, the Unit
Chaplain, or the Unit S-1 Personnel Office.
For civilians: A Letter is required from a clergyperson, an attorney, or your employer.
I understand that my separation is subject to investigation by the proper authorities. In addition, if I give
false or misleading information, I may be subject to a $20,000 fine, sent to prison, or both.
Separated Person's Signature:
Please return this completed form to: GTCC Financial Aid Office, PO Box 309, Jamestown, NC 27282
or FAX to 336-217-8468.
Financial Aid Office P.O. Box 309 Jamestown, NC 27282
Phone: 336.334.4822 Option 3 Fax: 336.217.8468
Notary’s Certificate of Acknowledgement
State of
City/County of /
On (Date) , before me (Notary’s Name), ,
personally appeared (Printed name of signer),
and proved to me on the basis of satisfactory evidence of identification (indicated in
Section A above) to be the above-named person who signed the foregoing
Notary Stamp or Seal
My commission expires on the
following date:
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