Financial Aid Office
2019-2020 Signature Page - Dependent Student
READ, COMPLETE, SIGN, AND DATE
If you are the student, by signing this application you certify that you
(1) will use federal and/or state student financial aid only to pay the cost of attending an institution of higher education,
(2) are not in default on a federal student loan or have made satisfactory arrangements to repay it,
(3) do not owe money back on a federal student grant or have made satisfactory arrangements to repay it,
(4) will notify your school if you default on a federal student loan, and
(5) will not receive a Federal Pell Grant from more than one school for the same period of time.
If you are the parent or the student, by signing this application you agree
if asked, to provide information that will verify the accuracy of your completed worksheet. This information may include your U.S. or
state income tax forms. Also, you certify that you understand that the Secretary of Education has the authority to verify information
reported on this application with the Internal Revenue Service and other Federal agencies. If you sign any document related to the
federal student aid programs electronically using a personal FSA User ID, you certify that you are the person identified by the FSA
User ID and have not disclosed that FSA User ID to anyone else. If you purposely give false or misleading information, you may be
fined $20,000, sent to prison, or both.
Everyone whose information is given on this worksheet should sign below. The student (and at least one parent, if
parent information is given) MUST sign below.
STUDENT
Name:_______________________________________________________
Date of Birth: _________________ Phone Number: ____________________
Student ID#: __________________ Social Security Number: ______________________
Student Signature: ___________________________________________
PARENT 1/MOTHER/STEP-MOTHER
Parent Name:________________________________________________
Parent Date of Birth:_______________________________
Parent Social Security Number:__________________________
Parent Marital Status:_______________________________
Parent Date of Marriage, Separation, Divorce, or Widowed:________________________
Parent 1/Mother/Step-Mother Signature:___________________________
PARENT 2/FATHER/STEP-FATHER
Parent Name
:________________________________________________
Parent Date of Birth:________________________________
Parent Social Security Number:__________________________
Parent Marital Status:_______________________________
Parent Date of Marriage, Separation, Divorce, or Widowed:________________________
Parent 2/Father/Step-Father Signature:________________________________
Please return this completed worksheet to:
Caldwell Campus
Watauga Campus
2855 Hickory Blvd.
P.O. Box 3318
Hudson, NC 28638
Boone, NC 28607
Fax: 828.726.2709
Fax: 828.297.1729
Email: finaid@cccti.edu
Email: finaid@cccti.edu
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