Lorain County Community College Financial Services 1005 N. Abbe Rd, Elyria, OH 44035 Phone: 440-366-4034
Drug Offense Conviction Worksheet
2020-21 Financial Aid Year
Section 1. Student Information
Last Name First Name Middle Initial
LCCC Student ID #
According to the information on your FAFSA (Free Application for Federal Student Aid), you either answered "yes" to Question 23 ("Have you ever
been convicted of possessing or selling illegal drugs?") or you left the question blank. As a result, you need to complete this worksheet and return
it to the Office of Student Financial Aid before we can determine your financial aid eligibility. Section A. Letters of Explanation/Support. This form
must be accompanied by the following:
1. Have you ever received federal student aid?
Yes No. If "No," stop here. Sign form and return to our office.
2. Have you been convicted for possessing or selling illegal drugs?
Yes No. If "No," stop here. Sign form and return to our office.
3. Did the offense for possessing or selling illegal drugs occur during a period of enrollment for which you were receiving federal student aid
(grants, loans, and/or work-study)?
Yes
No. If "No," stop here. Sign form and return to our office.
4. Have you completed an acceptable drug rehabilitation program since your conviction?
Yes No
5. Do you have more than two convictions for possessing illegal drugs?
Yes No
6. Do you have more than one conviction for selling illegal drugs?
Yes No
7. Enter the date of your last conviction for possessing illegal drugs.
If you have no convictions for possessing drugs, skip to #9.
8. If you have only one conviction for possessing drugs, add one year to the date in question #7 and enter that date here. If you have 2
convictions for possessing drugs, add two years.
9. Enter the date of your last conviction for selling illegal drugs.
If you have no convictions for selling drugs, skip to #11.
10. If you have only one conviction for selling drugs, add two years to the date in #9:
11. Look at the dates for #8 and #10. Write the later one here. If there is only one date, enter it here.
Section 2: Certification
I certify that all of the information reported is complete and accurate. Warning: If you purposely give false or misleading information on this form,
you may be fined, sentenced to jail, or both. Electronic signatures will not be accepted. Please print this form to sign prior to submitting.
Student signature: Date:
Section 3: Submission
Do not submit this form until you have gathered all other required documents/forms to avoid delays in processing. When all required documents
have been gathered, you may submit your information by: a) mail to the address below; b) fax to 440-366-4634 or; c) deliver to Financial Services,
First Floor, Bass Library. Watch for two-sided documents. Be sure to include both sides when faxing. Do not email any documents with
personally identifiable information.
