PARENT REFUSAL TO COMPLETE FAFSA
(2019-2020 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-110-PARF20 20181220
Most unmarried students under the age of 24 are considered dependent for federal financial aid purposes and must provide
parental information. In cases where parents provide absolutely no financial support for the student and refuse to provide their
information on the student’s FAFSA, the student may submit this request along with a Federal Direct Loan Request Form to
receive only unsubsidized loans.
Who is required to sign this form?
1. Parent(s) whose information would have been used to complete the FAFSA:
2. If student’s parents are legally married, both signatures are required.
3. If parents are divorced or legally separated, the parent who the student lived with or the parent who most recently
provided the most financial support is required to complete the form.
Parent(s) must initial each statement below indicating they understand the impact of this request:
___ ___ I do not and will not provide any financial support to my child, including but not limited to: cash support, non-cash
support such as room & board, use of my vehicle, health or car insurance coverage, groceries, rent, utilities, tuition,
books, schools supplies, or co-signing any type of loan for student.
___ ___ I stopped financially supporting my child on:
___ ___ It is in the student’s best interest to submit a FAFSA with parent’s income & household information. This may allow
for the student to qualify for a subsidized loan, which is better than an unsubsidized loan.
___ ___ My child, will only be eligible for federal unsubsidized loans if this request is approved.
___ ___ Interest will immediately begin accruing on my child’s loan.
___ ___ If this request is approved, my child will not be eligible for financial aid including but not limited to:
Federal Pell Grant; Federal SEOG Grant, Federal Work Study
Financial need-based scholarships
Federal subsidized student loans; Federal parent PLUS loans
I certify that I refuse to provide income & household information on the Free Application for Federal Student Aid (FAFSA), my financial
support of my child has ended and I will not provide any financial support, as indicated above, in the future. I understand that this
request impacts financial aid only at CCC for the 2019-2020 academic year. I certify that the information provided on this form is
complete and accurate to the best of my knowledge. I understand that submission of false information may result in a delay or denial of
federal financial aid and may subject me to criminal charges. I understand that purposely giving false or misleading information may
result in a fine of up to $20,000, being sent to prison, or both.
Print name of biological or adoptive parent Print name of biological or adoptive parent
Signature of biological or adoptive parent Signature of biological or adoptive parent
Phone # (include area code) Date Phone # (include area code) Date
I understand that the decision made on the basis of this request only affects my application for federal student aid at CCC for the 2019-
2020 academic year. I certify that the information provided on this form is complete and accurate to the best of my knowledge. I
understand that submission of false information may result in a delay or denial of federal financial aid and may subject me to criminal
charges. I understand that purposely giving false or misleading information may result in a fine of up to $20,000, being sent to prison, or
both.
Student Signature Date
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
