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P0111062020
Incarcerated Student Disclosure Form
This form is required to determine Federal Title IV Student Aid eligibility while incarcerated and attending GCU.
StudentName:_________________________________GCUStudentNumber:___________________
Are you currently incarcerated? _____ Yes _____ No (if no, date of release: ______________________)
Name of facility of incarceration: __________________________________________________________
City of incarceration: ______________________________ State of incarceration: __________________
Select type of facility: _____ Federal facility (including those operated by or contracted by the federal government)
_____ Local, municipal, or country facility (jail, penitentiary, or correctional)
_____ Half-way house
_____ Involuntary civil confinement facility (e.g. home detention)
_____ Juvenile Justice facility
Have you been convicted?
If no, when is your scheduled trial date?
Was your conviction for a forcible or non-forcible sexual offense?
Is your sentence required to be served only on weekends?
_____ Yes _____ No
__________________
_____ Yes _____ No
_____ Yes _____ No
StudentSignature*:_________________________________________ Date:____________________
Note: Handwritten signature required. Electronic signatures are not acceptable.
WARNING: If false or misleading information is purposely provided on this form, the student may be fined,
sent to prison, or both
