Form – 3
Mail to: NCC Financial Aid
P.O. Box 7488
Rocky Mount, NC 27804
Number of Household Members and Number in College
(Independent Student)
Name __________________________________________ NCC Student ID ____________________________
List below the people in the student’s household
. Include:
The student.
The student’s spouse, if the student is married.
The student’s or spouse’s children if the student or spouse will provide more than half of their support from July 1,
2020, through June 30, 2021, even if the children do not live with the student.
Other people if they now live with the student and the student or spouse provides more than half of their support
and will continue to provide more than half of their support through June 30, 2021.
For any household member who will be enrolled at least half time in a degree, diploma, or certificate program at an
eligible postsecondary educational institution any time between July 1, 2020, and June 30, 2021, include the name of
the college.
If more space is needed, provide a separate page with the student’s name and NCC ID number at the top.
Full Name (Please Print)
Will be Enrolled at Least
Half Time
(Yes or No)
Note: We may require additional documentation if we have reason to believe that the information regarding the
household members enrolled in eligible postsecondary educational institutions is inaccurate.
Certification and Signature
Each person signing below certifies that all of the
information reported is complete and correct.
________________________________________ ________________________
Print Student’s Name NCC Student Number
________________________________________ ________________________
Student’s Signature (Required) Date
________________________________________ ________________________
Spouse’s Signature (Optional) Date
WARNING: If you purposely give false or
misleading information you may be fined,
be sentenced to jail, or both.