CCC ID# OR LAST 4# OF SSN STUDENT NAME ______________________________________ ______________
This information is required even if you do not live with your legal parents (biological, adoptive, or as determined by the
If your legal parents are married to each other, or are not married to each other and live together, answer the
questions about both of them.
If your parent never married, has divorced/separated, or is widowed, only include your information about the
parent you lived with more during the past 12 months.
If your parent is remarried, include information for your parent and stepparent.
Never married Divorced or separated______________________
Month and Year
Widowed Married or remarried_______________________ ________________________________
Month and Year Month and Year
Unmarried and both legal parents living together
SSN:SSN: _____________________________________ _______________________________________
Last Name:Last Name: ________________________________ __________________________________
First Name:First Name: ________________________________ __________________________________
Date of Birth:Date of Birth: _______________________________ _________________________________
State of Legal Residence: ___________________________________________________________________
If no, Residence Date: __Legal Residents before 1-1-2015? ______________ _______________________
Cash, Savings, and Checking balance $_______________________________________________________
Net Worth of Investments (CDs, stocks, bonds, mutual funds, value of owned rental property) $____________
Net Worth of Business/Investment Farm $______________________________________________________
At any time during 2018 or 2019, did the student, the student’s parents, or anyone in the student’s parents’
household receive benefits from any of the federal programs listed? Check all that apply.
Medicaid or Supplemental Security Income (SSI) Supplemental Nutrition Assistance Program (SNAP)
Free or Reduced Price School Lunch Temporary Assistance for Needy Families (TANF)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Signing below certifies that all of the information reported is complete and correct.
An electronic signature is not valid.
Please return this form to the Financial Aid Office at the location you plan to attend. Central does not encourage faxing or
emailing information that has any personal identifiable information included.
Central Community College Columbus PO Box 1027 Columbus, NE 68602-1027
Central Community College Grand Island PO Box 4903 Grand Island, NE 68802-4903
Central Community College Hastings PO Box 1024 Hastings NE 68902-1024
Central Community College Kearney PO Box 310 Kearney, NE 68848-0310
WARNING: If you purposely give
false or misleading information,
you may be fined, sent to prison,
or both.