Last Name First Name MI MTC ID
Address City State Zip Code
Phone Number
I request a waiver to the Lottery Tuition Assistance eligibility requirement relating to the submission of the Free
Application for Federal Student Aid (FAFSA) for the following reason (check all that apply):
I am a high school student enrolled in a dual enrollment program.
I have already earned a Bachelors Degree and have provided an official transcript to the MTC Admissions
I am enrolled in a program that is not eligible for Title IV federal aid.
I am a dependent student who cannot get my parents signature or Tax Return Transcript. (You must attach
a letter from your parents confirming this statement)
I am an independent student who cannot get my spouses Tax Return Transcript.
I am an independent student and my adjusted gross income is at least $80,000. I will provide a copy of my
Federal Tax Return Transcript.
I am a dependent student and my parents adjusted gross income is at least $80,000. I will provide a copy of
their Federal Tax Return Transcript.
I will not be eligible to receive other Title IV aid, which includes the Pell Grant, Federal Supplemental Educational
Opportunity Grant, Perkins Loan, Direct Loans, Federal Work Study, and the SC Need-Based Grant. Also, I will not be
able to participate in programs that require the submission of the FAFSA. Further, I understand that neither the state of
South Carolina nor the institution can be held liable for any amount of federal or state funds that I forgo by signing this
I do not owe a refund or repayment of a state grant, Pell Grant, or Supplemental Educational Opportunity Grant, or any
other federal grant and I am not in default on a loan under the Federal Perkins Loan, Federal Stafford Loan, William D.
Ford Federal Direct Loan, or any state loans. I understand that the institution will verify this.
Male Students Only: I have registered with the Selective Service or I have been exempted from this requirement
according to federal law. I understand that students who fail to register with the Selective Service or fail to be exempt
from that requirement are not eligible to receive Lottery Tuition Assistance.
The provided information is correct and if any of the information is false, I understand participation in the
Lottery Tuition Assistance Program will be canceled and reimbursement of Lottery Tuition Assistance funds will
be required. Further, I understand that if I have attempted to obtain, or have obtained Lottery Tuition Assistance
through means of a willfully false statement or failure to reveal any material fact, condition, or circumstance affecting
eligibility, I can be subject to the college/university’s code of student conduct and applicable civil or criminal penalties.
This waiver is not valid until all requested documentation is provided to the financial aid office, and all documentation
has been verified.
Student Signature Date
Financial Aid Signature Date
Not Approved
MIDLANDSTECH.EDU | PO Box 2408 | Columbia, SC 29202 | 803.738.7792
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