Dr. H.A. Miller Student Services Center
417 Schepps Blvd., Clovis, NM 88101
Ph. (575) 769-4060 * Fax (575) 769-4027
Changes to Original Loans
CCC ID Social Security Number Name
Street Address City State Zip
Phone Number Email Address Date of Birth
Loan Information
I wish to cancel all of my loan disbursement.
I wish to cancel a portion of my loan disbursement.
$ Amount
I wish to request additional loan funds.
For what semester will the additional funds be for?
Fall Spring Summer
Type and amount of additional funds requested:
$ $
Subsidized Unsubsidized
Read & Initial
I understand:
I must be enrolled in 6 credit hours each semester I request a loan.
Loan amounts cannot exceed yearly loan limits or my unmet need.
All remaining balances on my account will be taken out of my loan.
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:
For Office Use Only:
Banner Updated
FA Initials:
click to sign
click to edit
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