2019-20 DEPENDENT VERIFICATION FORM
Please complete this form on a computer, or use black or blue ink.
STUDENT NAME _____________________________________ CCC ID# OR LAST 4# OF SSN __________________
A
DDRESS ______________________________________________ PHONE ______________________________
C
ITY _____________________________________ STATE _________________ ZIP CODE __________________
Your application was selected for review in a process called “Verification.” In this process, our office may be comparing
information from your application with copies of you and your parents’ 2017 financial documents. We are legally required
to collect and review this information before awarding Federal aid. If there are differences between your application
information and your financial documents, the Financial Aid Office will make corrections to your Student Aid Report (SAR).
Complete this verification form and submit it with any other requested documents to your financial aid office as soon as
possible. Failure to return the requested information will delay the processing of your financial aid.
HOUSEHOLD SIZE AND NUMBER IN COLLEGE
List yourself and all family members that will be living in your parent(s) household between July 1, 2019 and June 30,
2020. Include your parent(s) whose information was used when filling out your FAFSA. Also include your siblings living at
home if parent(s) will provide more than half their support. Include siblings if attending college and were required to use
parent income information when applying for federal student aid.
L
IST
F
ULL
N
AME OF
A
LL
F
AMILY
MEMBERS LIVING IN PARENT(S)
HOUSEHOLD IN 2019-20
AGE
R
ELATIONSHIP
TO
STUDENT
LIST COLLEGE ATTENDING AT
LEAST HALF-TIME IN 2019-20
Self
Central Community College
HOLD
CERTIFICATION STATEMENT
Each person signing below certifies that all of the information reported is complete and correct. The student and one
parent whose information was reported on the FAFSA must sign and date. An electronic signature is not valid.
_______________________________________________________________
S
TUDENT SIGNATURE DATE
_______________________________________________________________
P
ARENT SIGNATURE DATE
Please return this form to the Financial Aid Office at the location you plan to attend:
Central Community College Columbus PO Box 1027 Columbus, NE 68602-1027 Fax: 402-562-1290
Central Community College Grand Island PO Box 4903 Grand Island, NE 68802-4903 Fax: 308-398-7407
Central Community College – Hastings PO Box 1024 Hastings NE 68902-1024 Fax: 402-461-2447
Central Community College Kearney PO Box 310 Kearney, NE 68848-0310 Fax: 308-338-4041
WARNING: If you purposely give
false or misleading information,
you may be fined, sent to prison,
or both.
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