2019-20 INSTITUTIONAL STUDENT INFORMATION RECORD
READ, SIGN, AND DATE
If you are the student, by signing this application you certify that you (1) will use federal and/or
state student financial aid only to pay the cost of attending an institution of higher education,
(2) are not in default on a federal student loan or have made satisfactory arrangements to
repay it, (3) do not owe money back on a federal student grant or have made satisfactory
arrangements to repay it, (4) will notify your school if you default on a federal student loan, and
(5) will not receive a Federal Pell Grant from more than one college for the same period of time.
If you are the parent or the student, by signing this application you certify that all of the
information you provided is true and complete to the best of your knowledge and you agree, if
asked, to provide information that will verify the accuracy of your completed form. This
information may include U.S. or state income tax forms that you filed or are required to file.
Also, you certify that you understand that the Secretary of Education has the authority to verify
information reported on this application with the Internal Revenue Service and other federal
agencies. If you sign any document related to the federal student aid programs electronically
using a personal identification number (PIN), username and password, and/or other any other
credential, you certify that you are the person identified by the PIN, username and password,
and/or other credential, and have not disclosed that PIN, username and password, and/or
other credential to anyone else. If you purposely give false or misleading information, you may
be fined $20,000, sent to prison, or both.
Everyone whose information is given on this form should sign below. The student (and at least
one parent, if parent information is given) MUST sign below.
Student Signature__________________________________________ Date:________________
Print Student Name______________________________________________________________
Student Social Security Number____________________________________________________
Parent Signature___________________________________________ Date:________________
Print Parent Name_______________________________________________________________
Parent Social Security Number_____________________________________________________
Please return this original form to the Financial Aid Office at the location you plan to attend. This form
cannot be faxed or emailed.
Central Community College – Columbus PO Box 1027 Columbus, NE 68602-1027
Central Community College – Grand Island PO Box 4903 Grand Island, NE 68802-4903
Central Community College – Hastings PO Box 1024 Hastings NE 68902-1024
Central Community College – Kearney PO Box 310 Kearney, NE 68848-0310