Social Security Number:
I certify that the above-named individual is out of the work forces as a result of a permanent
disability and is receiving a social security disability benefit (SSDI) or supplementals security
income (SSI) as defined by the Social Security Act, Railroad Retirement Act, or in the case of a
former federal employee, from the federal retirement or pension authority (U.S. Office of
Personnel Management).
Individuals receiving SSI or SSDI benefits as a dependent or survivor of a disabled beneficiary do
not qualify for this waiver.
Printed Name of Certifying Official
Signature of Certifying Official
Phone Number
Student Signature
(Student signature authorizes the Social Security Administration to release information on the
above named individual and acknowledges that this form is valid for one academic year and
must be renewed each academic year. In addition, student acknowledges that he/she must
apply for financial aid.)
Return this completed form to:
Frederick Community College
Enrollment Center, Room J-100
7932 Opossumtown Pike
Frederick MD 21702
Place Office Stamp in Box