(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110
Students who are awarded, but wish to opt out of the CCC Bookstore voucher must complete the table below and provide a printout of
the book cost or school supply information from the vendor. Funds for the amount of books and/or supplies sold by the vendor will be
issued to you no later than the end of the first week of classes either by direct deposit or a check mailed to the address on Web4/Self
Service. If this Book Voucher Opt Out is approved, your Book Voucher at the CCC Bookstore will be canceled.
I wish to opt out of the Book Voucher for the following semester: Fall 2020 Spring 2021 Summer 2021
Name of Book or School Supply
CCC Bookstore
List name of Vendor
(, UT&T, etc.)
Vendor Price
Shipping + Handling
(if applicable)
Total Amount
If approved, I would like the funds disbursed to me in the following manner (choose one):
Direct Deposit (I have my financial aid set up for direct deposit)
Pick up a check at the CCC Lone Tree Campus
Send a check to me at the address listed in Web4/Self Service
I understand that by opting out of the CCC Bookstore Voucher I will receive funds to be used for books and supplies in the amount
listed on this form and official estimate on printout and will have my Bookstore Voucher canceled at the CCC Bookstore. I authorize
CCC to pay this Bookstore Voucher Opt Out using my financial aid.
Student Signature and Date
How do I create a digital signature with Adobe?
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
Office of Student Financial Aid Use Only
Approved Denied Amount $ Processed By:
Comments:_____________________________________________________________________________________________ Date___________
I certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving false or misleading
information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent to prison or both. I hereby
provide consent for the use of electronic records and signatures on all financial aid documents. I understand that if I choose to sign
electronically, my electronic signature constitutes a binding contract and may not be denied legal effect, validity, or enforceability
solely because it is in electronic form or because an electronic signature or electronic record was used in its formation.
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