Waycross Campus (912) 287-6584
Jesup (912) 427-5800
Alma (912) 632-0951
Camden (912) 510-3327
Hazlehurst (912) 379-0041
Baxley (912) 367-1700
Golden Isles (912) 262-4999
Website: www.coastalpines.edu
Financial Aid Information Form
Aid Year: 2020-2021
Student ID#: __
________________
This form must be completed and returned to the Financial Aid Office each financial aid year beginning July 1.
Printed Name _____________________________________________________________________________________________
List any other prior names used, including maiden name: __________________________________________________________
Date of Birth _________________________________ Phone # _____________________________________________________
Mailing Address ___________________________________________________________________________________________
City, State, Zip __________________________________________________________________ County ____________________
What is your intended program of study? _______________________________ Certificate Diploma Associate
Are you listed as a dependent on a parent or legal guardian tax return? YES NO (Must submit copy of state tax return.)
If you are under 24 and answered yes to the question above, you are a dependent student for the purpose of determining HOPE
eligibility. As a dependent student, your residency will be the same as your parent or guardian.
Are you a GA resident? YES NO Date you moved to GA (mm/dd/yy) _________________(If born in GA, enter date of birth)
Is your parent or guardian a GA resident? YES NO Date your parent or guardian moved to GA (mm/dd/yy) _______________
Must submit copies of any two documents from the following list for proof of residency:
GA income tax return, GA driver’s license, GA voter registration card, GA state ID, or GA property tax card or receipt.
Do you have a GED? YES NO. If yes, was it obtained in GA? YES NO If yes (location) ____________________
Do you have a high school diploma? YES NO. If yes, was it obtained in GA? YES NO
Name of high school from which you graduated: ______________________________ Date (mm/dd/yy) of graduation___________
Are you a veteran? YES NO (Must submit copy of DD214.)
Are you currently “active duty military,” other than training? YES NO (Must submit copy of orders.)
CERTIFICATION STATEMENT ON REFUNDS & DEFAULT:
I certify that I do not owe a refund on any federal or state grant or loan, am not in default on any federal or state loan or have made satisfactory arrangements to repay
any defaulted federal or state loan, and have not borrowed in excess of the loan limits under Title IV programs at any institutions.
STATEMENT OF EDUCATIONAL PURPOSE
I certify that I will use all financial aid monies received only for expenses related to my study at Coastal Pines Technical College. I agree to return any funds I have
received for which I am not eligible.
CERTIFICATION STATEMENT ON USE OF CONTROLLED SUBSTANCES
I certify that, as a condition of financial aid, I must not engage in the unlawful manufacture, distribution, dispensation, possession or use of a controlled substance
during the period covered by financial aid.
Authorization:
Program regulations permit students to authorize use of Title IV financial aid funds (Federal Pell Grant and Federal Supplemental Education Opportunity Grant) for
non-institutional charges. If you are eligible for Federal Financial Aid in excess of tuition and fees, and you wish to use this excess to cover other charges, you must
authorize Coastal Pines Technical College to pay these charges from your account balance.
You may cancel this authorization at any time prior to incurring such payment of charges, but you may not cancel it once such payment of charges has been made on
your behalf. By signing, I authorize Coastal Pines Technical College to use the appropriate funds to pay for allowable charges other than tuition and mandatory fees.
Allowable charges that are not automatically paid by Student Aid Funds and therefore require authorization include books and supplies, malpractice insurance,
instructional technology fee, parking fees, parking fines, lab fees, graduation fees, testing fees, dosimeter badges, program assessment examinations, on-line review
courses, registry certification fees, simulated board and certification exams and any program specific fees.
Signature __________________________________________________________ Date ______________________________________
Equal Opportunity Institution
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