Dr. H.A. Miller Student Services Center Budget Revision Request
417 Schepps Blvd., Clovis, NM 88101
2020-2021
Ph. (575) 769-4060 * Fax (575) 769-4027
CCC ID: Name:
I request that my cost of attendance budget be revised due to the following reasons:
Travel:
City: State: Zip Code:
Child Care Expenses: statement from childcare provider required
Child Care Provider: Number of Children:
Number of Hours per week per child: Cost per Hour:
Program Fees:
Name of Program: Amount of Additional Fees:
Books - List Cost of Books:
Title: Title: Title:
Title: Title: Title:
Other:
SIGNATURE REQUIRED
By signing this worksheet you certify 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, be sentenced to jail, or both.
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Student Signature: Date:
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ForOfficeUseOnly

Budget OriginalBudget RequestedAdjustment ReasonforAdjustment RevisedBudget
Tuition    
Fees    
Roomand    
Books    
Travel    
Dependen    
Disability    
Miscellane    
Other     Ini Date
Total:      
Revised3‐12‐2019
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