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Additional Information Statement Save

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Dr. H.A. Miller Student Services Center
417 Schepps Blvd., Clovis, NM 88101
Ph. (575) 769-4060 * Fax (575) 769-4027
CCC ID:
Additional Information
Statement
Name:
SIGNATURE REQUIRED
By signing this statement 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.
Student Signature:
Parent Signature:
Financial Aid Specialist:
Date:
Date:
Date:
Revised 9-28-2017
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Completed 5 November 2019

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