PARENT REFUSAL TO COMPLETE FAFSA
(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 firstname.lastname@example.org
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 or the parent who most recently
provided the most financial support 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:
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 understand that this
request impacts financial aid only at CCC for the 2019-2020 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.
Must be signed and mailed to CCC
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 2020-2021
academic year. I certify that the information provided on this form is complete and accurate to the best of my knowledge. I understand that
submission of false information may result in a delay or denial of federal financial aid and may subject me to criminal charges. I understand
that purposely giving false or misleading information may result in a fine of up to $20,000, being 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?
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
click to sign
click to edit