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