California Lutheran University – Office of Financial Aid
2015-16 Agency Certification – Untaxed Income
CLU Office of Financial Aid
60 West Olsen Road #1375
Thousand Oaks, CA 91360
EMAIL: finaid@callutheran.edu
FAX: (805) 493-3114
Federal and state regulations relative to student financial aid mandate coordination and
verification of all family financial resources. The information provided below will be used only to
determine financial aid eligibility and will be kept confidential by the campus pursuant to the
Family Education Rights and Privacy Act (FERPA).
To be completed by the Student and Spouse if applicable and/or Parent before submitting to Agency. By signing below, you are
agreeing to authorize the appropriate office/agency to provide the information requested by the school listed above.
CLU ID # or Social Security Number
Case Name under which benefits are paid (please print)
Applicant’s Spouse’s Signature (if applicable)
Mother's Social Security Number
Father's Social Security Number
To be completed by the Agency providing benefits:
□ Assistance is NOT issued by this Agency to any of the person(s) named above.
□ No record
□ Not eligible (Reason) __________________________________________________________________________________
□ Assistance is issued by this Agency to at least one of the person(s) named above.
Benefits received for the entire family, including applicant, include:
Benefit(s) began
(Month/Year)
Current Benefits
Monthly Amount
Is change or termination of benefit(s) anticipated during the year? □ YES □ NO
If yes, explain change and provide date of change:
Agency Representative (type or print name)
PLEASE RETURN TO CALIFORNIA LUTHERAN UNIVERSITY AT THE ADDRESS LISTED ABOVE.
