2020 – 2021 Institutional Student Information Record Signature Page
Financial Aid Office, P.O. Box 917, Henderson, NC 27536
Telephone: (252) 738-3280, Fax: (252) 738-3388, Email: fao@vgcc.edu
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 college 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 any other credential, you certify that you are the person identified by that 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 up to $20,000, sent to prison, or both.
Student Name: ________________________________________ Student ID#: ____________________
Student’s Signature: ____________________________________ Date: __________________________
Parent’s Signature: _____________________________________ Date: __________________________
Parent 1 (on the FAFSA)
Parent Name: __________________________________________________________________________
Parent Relationship to Student: ___________________________________________________________
Parent Date of Birth: __________________ Parent Social Security Number: _______________________
Parent 2 (on the FAFSA)
Parent Name: __________________________________________________________________________
Parent Relationship to Student: ___________________________________________________________
Parent Date of Birth: __________________ Parent Social Security Number: _______________________
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2020-2021 ISIR Signature Page Revised Date: 07/01/2020/FAO
