YubaCommunityCollegeDistrict
F
inancial
A
id
O
ffices
DeclineFinancialAidAwardsfor20192020
_____________________________________________________ _______________________________
LastName  FirstStudentID
_____________________________________________________  _______________________________
MailingAddressPhoneNumber(Includeareacode)
_____________________________________________________
City State ZipCode
STUDENT:Completethissection.
1.Iamrequestingtodeclinefinancialaidforthefollowingsemester(s):
Fall2019Spring2020Summer2020
2.Iamdecliningthefollowinggrants/awards:
PellGrantFederalWorkStudyFSEOGCALGrantEOPSCARE
Scholarship(s)
Other:_________________________________________________________
3.Iamrequestingtocancelmyfinancialaidaward(s)forthefollowingreason(s):
__________________________________________________________________________________________
__________________________________________________________________________________________

Note:Ifyouhavealreadyreceivedfinancialaidfundsforatermselectedabove,youmustrepayallfinancialaid
fundsbeforethisrequestcanbeprocessed.
Certification:Ihavereadandunderstandtheinformationstatedonthisform.Icertifythattheinformationprovidedonthisformis
trueandcorrecttothebestofmyknowledge.Iunderstandthatthisinformationwillbeusedtodeterminemyeligibilityandthatfalse
ormisleadinginformationmaybe
causefordenial,termination,and/orrepaymentoffinancialaidfunds.
_________________________________________________  _______________________________
StudentSignatureDate
FINANCIALAIDOFFICEUSEONLY
Awarded(s)Adjusted/Amended:PellFWSFSEOGCALGrantEOPSCARE
Scholarship(s)Other:__________________________________________________________________________
Term:Fall2019Spring2020Summer2020
Comments:_________________________________________________________________________________________
___________________________________________________________________________________________________
______________________________________________ ___
FinancialAidSignatureDate 

10/10/18
YubaCollege
2088NorthBealeRoad
Marysville,CA95901
5307497999
WoodlandCommunityCollege
2300EastGibsonRoad
Woodland,CA95776
5306615725
LakeCounty Campus
15880DamRoadExtension
Clearlake,CA95422
7079957923
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