Fillable Initial Application (Alabama Commission on Higher Education)

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Initial Application (Alabama Commission on Higher Education)

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ALABAMA COMMISSION ON HIGHER EDUCATION
Grants and Scholarships Department
P.O. Box 302000
Montgomery AL 36130-2000
APPLICATION AND CERTIFICATION
OF ELIGIBILITY UNDER THE POLICE OFFICER’S AND
FIREFIGHTER’S SURVIVORS EDUCATIONAL ASSISTANCE PROGRAM
Name of Applicant:
(Last) (First) (Middle)
Social Security Number:___ ___ ___ - ___ ___ - ___ ___ ___ ___ Email Address:
Mailing Address:
(Rural Route or Street and Number)
(City) (State) (Zip Code)
Home Telephone: ________________ Cellphone: ___________________ Work Telephone:
Relation of Applicant to Law Enforcement Officer, Firefighter, or Rescue Squad Member: (Check one)
_____ Natural child who was under 21 at the time of death or total disability in the line of duty.
_____ Adopted child who was under 21 at the time of death or total disability in the line of duty.
_____ Spouse who has not remarried, and whose initial enrollment is within five years of the time of
death or within five years from September 1999 for total disability that occurred in the
line of duty.
Documentation attached: (Check one)
______ Copy of Birth Certificate for Natural Child
______ Copy of Adoption Papers for Adopted Child
Name of sworn full-time police officer, firefighter or rescue squad member killed or totally disabled in the line of
duty. Attach 1) certified copy of death certificate or letter from a qualified physician verifying the police officer,
firefighter or rescue squad member is totally disabled, and 2) a letter from the employer stating the officer,
firefighter or rescue squad member was killed or totally disabled in the line of duty.
(First) (Middle) (Last)
Officer was Employed by:
(Name of Agency, Department or City/County Government)
ACHE Date Stamp
Name of College or University
Terms Aid Is Requested (Please check) _____ Fall ______ Spring _________ Summer
I hereby certify that I have been accepted for enrollment, or am enrolled, as a student in good academic
standing at the institution noted above. I also acknowledge that the statements and attachments
included with this Application and Certification of Eligibility for benefits under The Code of Alabama 1975,
Sections 36-21-100 through 36-21-105 are true and correct.
_______________________________
Date Signature of Applicant
THE APPLICANT IS HEREBY CERTIFIED as qualified under the provisions of The Code of Alabama 1975,
Sections 36-21-100 through 36-21-105 and eligible for educational assistance
for undergraduate study at the postsecondary educational institution listed above.
__________________________________
Date Signature of Chair of the Tuition Eligibility Board
USE OF SOCIAL SECURITY NUMBER
Section 7(a) of the Privacy Act of 1974 (5 U.S.C. 522A) requires that when any Federal, State, or local
government agency requests an individual to disclose his/her Social Security account number, that
individual must also be advised whether that disclosure is mandatory or voluntary, by what statutory or
other authority the number is solicited, and what uses will be made of it.
Accordingly, applicants are advised that disclosure of their Social Security Account Number (SSAN) is required
as a condition for participation in the Police Officer’s and Firefighter’s Survivors Educational Assistance
Program in view of the practical administrative difficulties which the Program would encounter in
maintaining adequate program records without the continued use of the SSAN.
The SSAN will be used to verify the identity of the applicant and as an account number (identifier)
throughout the life of the scholarship in order to record necessary data accurately. As an identifier, the SSAN
is used in such Program activities as determining Program eligibility, certifying school attendance, making
and verifying scholarship payments, and maintaining records of scholarship payments. Authority for
requiring the disclosure of an applicant’s SSAN is in Section 7(a)(2) of the Privacy Act, which provides that an
agency may require disclosure of an individual SSAN as a condition for the granting of a right, benefit, or
privilege provided by law.
This form must be completed and returned to:
Alabama Commission on Higher Education
Grants and Scholarships Department
P.O. Box 302000
Montgomery AL 36130-2000
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Initial Application (Alabama Commission on Higher Education)

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Completed 29 July 2020

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