Fillable 2019-2020 Dr. H.A. Miller Student Services Center V1 (Clovis Community College)

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2019-2020 Dr. H.A. Miller Student Services Center V1 (Clovis Community College)

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The 2019-2020 Dr. H.A. Miller Student Services Center V1 (Clovis Community College) form is 2 pages long and contains:

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  • 6 check-boxes
  • 57 other fields

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File type: PDF

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Dr. H.A. Miller Student Services Center
417 Schepps Blvd. Clovis, NM 88101
Phone: (575) 769-4060 | Fax: (575) 769-4027
V1 Verification
2019-2020
Your 2019–2020 FAFSA has been selected for a review process called verification. The law states that before
awarding Federal Student Aid, we will ask you to confirm the information you (and your parents if applicable)
reported on your FAFSA. The financial aid administrator at your school will compare your FAFSA with the
information on this worksheet and with any other required documents. If there are differences, your FAFSA
information will be corrected. You (and at least one parent if dependent) must comp
lete and sign this worksheet
and submit it, along with other required documents, to the financial aid office. If you have questions about
verification, contact the financial aid office as soon as possible so that your financial aid will not be delayed.
CCC ID Social Security Number Last Name First Name MI
Street Address City State Zip
Phone Number Email Address Date of Birth
Name Address Telephone Relationship
Dependent Students: List below the people in your parent(s) household. Include:
•
Yourself and your parent(s) (including a stepparent) even if you do not live with them.
•
Your parent(s)’ other children if your parent(s) will provide more than half of their support from July 1, 2019, through June
30, 2020, or if the other children would be required to provide parental information if they were completing a FAFSA for
2019–2020. Include children who meet either of these standards, even if they do not live with your parent(s).
•
Others if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue to
provide more than half of their support through June 30, 2020.
Independent Students: List below the people in your household. Include:
Your spouse, if you are married.
Your children, if any, that you will provide more than half of their support from July 1, 2019, through June 30, 2020, or if the
child would be required to provide
your
information if they were completing a FAFSA for 2019–2020. Include children who
meet either of these standards, even if they do not live with you.
Other people living with you which you provide more than half of their support and will continue to provide more than
half of their support through June 30, 2020
Include the name of the college for any household member who will be enrolled at least half time in a degree, diploma, or
certificate program at a postsecondary educational institution any time between July 1, 2019, and June 30, 2020.
Please read guidelines above before completing.
Household Members
Age
Relationship to Student
College Name
Self
Clovis Community College
Please complete second page
Instructions
Student Information
Reference/Emergency Contact
Household Information
Income Information to be Verified
Please check the box that applies:
I have filed my 2017 return and used the IRS Data Retrieval
Tool to transfer my income information.
I am attaching an IRS Tax Return Transcript.
I did not work/I did work in 2017 but was not required to file. I
am providing an IRS Verification of Non-Filing Letter, and if
applicable, my IRS Wage and Income Transcript.
Please check the box that applies:
My Parents have filed their 2017 return and used the IRS Data
Retrieval Tool to transfer their income information.
My Parents are attaching an IRS Tax Return Transcript.
My Parents did not work/did work in 2017 but they were not required
to file. They are providing an IRS Verification of Non-Filing Letter and,
if applicable, their IRS Wage and Income Transcript.
2017 Untaxed Income
Student/Spouse
Income Sources
Parent(s)
$
Active Duty/BAS Allowance
$
$
Untaxed Pensions
$
$
Education Credits
$
$
IRA Deductions
$
$
Tax Exempt Interest
$
$
Untaxed IRA Distributions
$
$
Other Untaxed Income (please specify):
$
I authorize CCC to credit any financial aid I receive to my student account to pay for tuition, fees, bookstore charges and
any
other charges I may incur. I understand that all charges will automatically be deducted from my financial aid. If my
financial
aid is canceled for any reason or if my financial aid does not cover all my charges, I will be responsible for paying any balance
owed to CCC. I further understand that if I fail to pay these charges by midterm of the semester I
incurred them, a hold may be
placed on my registration and my academic records. I will also be responsible for paying all
costs necessary for collections
including legal costs and attorney fees plus interest on my account balance at the statutory
rate. Furthermore, I understand
that if I do not authorize this deferment and I do not pay my charges by
the scheduled deadlines my classes may be dropped.
Please INITIAL
that you understand the Deferment Authorization Agreement: Date:
Signature(s) Required
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. Warning:
If
you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
Student’s Signature: _____________________________________________ Date:
Parent’s Signature: (If dependent): ______________________________________ Date: ____________________________
Revised 11-19-18
Student (& Spouse, if applicable):
Parents (Dependent students only)
Deferment Authorization Agreement – Students may cancel this DAA at any time in writing
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2019-2020 Dr. H.A. Miller Student Services Center V1 (Clovis Community College)

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Completed 26 July 2020

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