COMMUNITY COLLEGE OF ALLEGHENY COUNTY
Allegheny Campus Boyce Campus North Campus South Campus
808 Ridge Avenue 595 Beatty Road 8701 Perry Highway 1750 Clairton Road
Pittsburgh, PA 15212 Monroeville, PA 15146 Pittsburgh, PA 15237 West Mifflin, PA 15122
Ph: 412.237.2589 Ph: 724.325.6602 Ph: 412.369.3656 Ph: 412.469.6241
FAX: 412.237.3171 FAX: 412.237.3173 FAX: 412.237.3175 FAX: 412.237.3177
2019-20 STUDENT WITHDRAWAL CLEARANCE LETTER
Dear Student,
In order to determine your federal loan and/or Pell grant eligibility at the Community College of Allegheny
County, we are required to review your student loan/Pell grant history. As a result of our inquiry into the National
Student Loan Database System, it appears you are or were attending another institution during the current
academic year. In order to ensure that you are awarded in compliance with Federal Regulations, we will need you
to obtain the following information from your previous/current school before we are able to process any financial
aid at the Community College of Allegheny County. Thank you for your cooperation.
Please sign to give authorization to release information:
Printed Student Name:
Student Signature:
SSN:
Date:
The information below must be completed by a Financial Aid Administrator at your previous school.
Student’s official last day of attendance:
Pell Grant amount disbursed: $
Gross Stafford loan amounts disbursed: Sub: $ Unsub: $
Loan Period to
Have future disbursements been cancelled? Yes or No
School Certifying Official:
Name (PRINT): Date:
Institution Name:
Address:
City/State/Zip Code:
Phone: Fax:
Email:
Signature/Date:
PLEASE RETURN COMPLETED FORM TO THE CAMPUS YOU ARE ATTENDING
Notifications of nondiscrimination and contact information can be found at www.ccac.edu, search keywords “notifications of nondiscrimination.
click to sign
signature
click to edit
click to sign
signature
click to edit
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome