Dr. H.A. Miller Student Services Center
417 Schepps Blvd. Clovis, NM 88101
Phone: (575) 769-4060*Fax: (575) 769-4027
INSTRUCTIONS
Custom V4
Verification
2019-2020
Your 2019–2020 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that before
awarding Federal Student Aid, we may ask you to confirm the information you and your parents reported on your FAFSA. To verify that you provided
correct information the financial aid administrator at your school will compare your FAFSA with the information on this worksheet and with any other
required documents. If there are differences, your FAFSA information may need to be corrected. You and at least one parent must complete and sign
this worksheet, attach any
required documents, and submit the form and other required documents to the financial aid administrator at your school.
Your school may ask for additional information. If you have questions about verification, contact your financial aid administrator as soon as possible so
that your financial aid will not be delayed.
STUDENT INFORMATION
CCC ID Social Security Number Last Name First Name MI
Street Address City State Zip
Phone Number Email Address Date of Birth
REFERENCE
Name Address Telephone Relationship
HOUSEHOLD INFORMATION
Dependent Students: List below the people in your parent(s) household. Include:
Yourself and your parent(s) (including a stepparent) even if you don’t live with your parent(s).
Your parent(s)other children if your parent(s) will provide more than half of their support from July 1, 2019, through June 30, 2020, or if the other
children would be required to provide parental information if they were completing a FAFSA for 2019–2020. Include children who meet either of these
standards, even if they do not live with your parent(s).
Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue to provide more than half
of their support through June 30, 2020.
Include the name of the college for any household member, excluding your parent(s), who will be enrolled, at least half time in a degree, diploma, or
certificate program at a postsecondary educational institution any time between July 1, 2019, and June 30, 2020. If more space is needed, attach a
separate page with the student’s name and CCC ID at the top.
Independent Students: List below the people in your household. Include:
Yourself.
Your spouse, if you are married.
Your children, if any, if you will provide more than half of their support from July 1, 2019, through June 30, 2020, or if the child would be required to
provide your information if they were completing a FAFSA for 2019–2020. Include children who meet either of these standards, even if they do not live
with you.
Other people if they now live with you and you provide more than half of their support and will continue to provide more than half of their support
through June 30, 2020.
Include the name of the college for any household member who will be enrolled
at least half time, in a degree, diploma, or certificate program at a
postsecondary educational institution any time between July 1, 2019, and June 30, 2020. If more space is needed, attach a separate page with your
name and CCC ID at the top.
Please read guidelines above before completing.
Student Name
Age
College Name
Self
Clovis Community College
Family Members
Age
Relationship to Student
College Name
Please complete second page
This Page
Intentionally
Left Blank
HIGH SCHOOL COMPLETION STATUS
Please provide and checkmark one of the following documents that indicate your high school completion status
when you will begin college in Fall 2019, Spring 2020 or Summer 2020:
A copy of the student’s high school diploma.
A copy of the student’s final official high school transcript that shows the date when the diploma was awarded.
A copy of the student’s High School Equivalency Credential certificate.
If State law requires a homeschooled student to obtain a secondary school completion credential for homeschool (other
than a high school diploma or its recognized equivalent), a copy of that credential.
If State law does not require a homeschooled student to obtain a secondary school completion credential for homeschool
(other than a high school diploma or its recognized equivalent), a transcript or the equivalent, signed by the students
parent or guardian, that lists the secondary school courses the student completed and documents the successful
completion of a secondary school education in a homeschool setting.
If you are unable to obtain documentation listed above, you must contact the CCC Financial Aid Office.
DEFERMENT AUTHORIZATON AGREEMENT Students may cancel this DAA at any time in writing.
I authorize CCC to credit any financial aid I receive to my student account to pay for tuition, fees, bookstore charges and
any other charges I may incur. I understand that all charges will automatically be deducted from my financial aid. If my
financial aid is canceled for any reason or if my financial aid does not cover all my charges, I will be responsible for paying
in full, any charges owed to CCC. I further understand that if I fail to pay these charges by midterm of the semester I
incurred them, a hold may be placed on my registration and my academic records. I will also be responsible for paying all
costs necessary for collections including legal costs and attorney fees plus interest on my account balance at the statutory
rate. Furthermore, I understand that if I do not authorize this deferment and I do not pay my charges (tuition, fees, etc.) by
the scheduled deadlines my classes may be dropped.
Please INITIAL that you understand the Deferment Authorization Agreement: _ Date: __
SIGNATURE(S) REQUIRED
Each person signing this worksheet certifies 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’s Signature: Date:
Parent’s Signature: (dependent student only) Date
Revised 03-12-19
Print
Submit
click to sign
signature
click to edit
click to sign
signature
click to edit
CCC ID Student Name: _
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (To be signed at the institution)
The student must appear in person at Clovis Community College to verify his or her identity by
(Name of Postsecondary Educational Institution)
presenting a valid-government-issued photo identification (ID), such as, but not limited to, a driver’s license,
other state-issued ID, or passport. The institution will maintain a copy of the student’s photo ID that is
annotated with the date it was received and the name of the official at the institution authorized to collect the
student’s ID.
In addition, the student must sign, in the presence of the institutional official, the following:
Statement of Educational Purpose
I certify that I am the individual signing this
(Print Student’s Name)
Statement of Educational Purpose and that the federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending
Clovis Community College
for 2019-2020.
(Name of Postsecondary Educational Institution)
(Student’s Signature)
(Date)
(Student’s ID Number)
Financial Aid Office Use Only
Copy of Photo ID Attached
RHACOMM Updated
Notarized
Archived
Received Date Stamp:
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