Flagstaff, AZ 86005-2701
PH: 928-226-4219
FAX: 928-226-4110
PARF22
FA-110-PARF22 20201214
PARENT REFUSAL TO COMPLETE FAFSA
(2021-2022 Academic Year)
Most unmarried students under the age of 24 are considered dependent for federal financial aid purposes and must provide
parental information. In cases where parents provide absolutely no financial support for the student and refuse to provide their
information on the student’s FAFSA, the student may submit this request along with a Federal Direct Loan Request Form to
receive only unsubsidized loans.
Who is required to sign this form?
1. Parent(s) whose information would have been used to complete the FAFSA:
2. If student’s parents are legally married, both signatures are required.
3. If parents are divorced or legally separated, the parent who the student lived with more during the last 12 months or the
parent who provided the most financial support in the last 12 months is required to complete the form.
Parent(s) must initial each statement below indicating they understand the impact of this request:
___ ___ I do not and will not provide any financial support to my child, including but not limited to: cash support, non-cash
support such as room & board, use of my vehicle, health or car insurance coverage, groceries, rent, utilities, tuition,
books, schools supplies, or co-signing any type of loan for student.
___ ___ I stopped financially supporting my child on this date:
___ ___ It is in the student’s best interest to submit a FAFSA with parent’s income & household information. This may allow
for the student to qualify for a subsidized loan, which is better than an unsubsidized loan.
___ ___ My child, will only be eligible for federal unsubsidized loans if this request is approved.
___ ___ Interest will immediately begin accruing on my child’s loan.
___ ___ If this request is approved, my child will not be eligible for financial aid, including but not limited to:
• Federal Pell Grant; Federal SEOG Grant, Federal Work Study
• Financial need-based scholarships
• Federal subsidized student loans; Federal parent PLUS loans
I certify that I refuse to provide income & household information on the Free Application for Federal Student Aid (FAFSA), my financial
support of my child has ended and I will not provide any financial support, as indicated above, in the future. I certify that information
provided on this form is true and complete to the best of my knowledge. Purposely giving false or misleading information may result in a
delay or denial of my federal financial aid and I may be fined up to $20,000, sent to prison or both.
Print name of biological or adoptive parent Print name of biological or adoptive parent
Signature of biological or adoptive parent (must be signed and mailed to CCC) Signature of biological or adoptive parent (must be signed and mailed to CCC)
Phone # (include area code) Date Phone # (include area code) Date
I understand that the decision made on the basis of this request only affects my application for federal student aid at CCC for the 2021-
2022 academic year. I certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving
false or misleading information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent to
prison or both. I hereby provide consent for the use of electronic records and signatures on all financial aid documents. I understand
that if I choose to sign electronically, my electronic signature constitutes a binding contract and may not be denied legal effect, validity,
or enforceability solely because it is in electronic form or because an electronic signature or electronic record was used in its formation.
Student Signature and Date How do I create a digital signature with Adobe?
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signature
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