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3041 West Avenue K, Lancaster, California 93536 Phone: (661) 722-6300 Ext.6337
EMERGENCY FINANCIAL ASSISTANCE
SELF-CERTIFICATION FORM
Emergency Financial Assistance to Low-Income Community College Students.
Student Eligibility Criteria:
Grants may be awarded to students who are California residents or are exempt from paying nonresident
tuition under §68130.5 of the California Education Code who self-certify that they meet the following
conditions:
Currently enrolled in 6-degree applicable units. This includes newly enrolled students.
Demonstrate an emergency financial aid need.
Qualify as low-income by meeting the requirements to receive a California College Promise
Grant (CCPG) or is projected to receive a CCPG for the upcoming term.
Earned a 2.0 grade point average at their current or prior institution in one of the previous three
semester terms (or four quarter terms) OR is a student who is receiving additional support or
services through a community college’s Disabled Student Programs and Services
Please complete the below self-certification form, attach supporting documentation and submit this
form to the financial aid office.
Student Name: ______________________________________ Student ID: ___________________
Telephone #:____________________________________
1.
Are you currently enrolled in 6-degree applicable units?
Yes No
2.
Have you earned a 2.0 grade point average at your current or prior institution in one of the previous
three semester terms? Yes No
2a. If no, select all that apply:
You receive additional support or services through the Disabled Student Programs
and Services.
You are a first-time student.
You have taken only Pass/No Pass or non-credit courses.
COVID-19 related issues.
Other: ______________________________________________________
3.
Have you been awarded a California College Promise Grant (fee waiver) for the 2020-21 or 2021-22
academic year? Yes No
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3041 West Avenue K, Lancaster, California 93536 Phone: (661) 722-6300 Ext.6337
4.
Amount Requested
$
_____________
5.
Please explain your emergency financial need and how the funds will support your education.
Please submit supporting documentation.
(Failure to submit supporting documentation will
result in your application being denied)
CERTIFICATION STATEMENT: By signing this document, you certify that the information you submit is
true. If you purposely give false or misleading information, you may be sent to prison, fined $20,000 or both.
Due to the high volume of applicants, it may take 3-4 weeks for a status update. Please note Emergency
Financial Assistance funds are limited.
Student Signature Date
You should make a copy of this worksheet for your records.
-THIS SECTION FOR FINANCIAL AID OFFICE USE ONLY-
RESULTS: Approved Denied
Financial Aid Signature Date
Comments:
_______________________________________________________________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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