(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110
FA-404-PRFDEP 2021 20200416
On the FAFSA you indicated you have a child or dependent whom you provide at least half of their support.
Do you have a child or children?
Yes No
If Yes, you must attach a copy of your child(ren)’s birth certificate showing you as the parent.
Are you pregnant?
Yes No
If yes, you must attach a doctor’s statement confirming pregnancy and your due date
occurring prior to 6/30/2021
Will your child(ren) receive more than half
of their support from you between July 1,
2020 and June 30, 2021?
Yes No
Do you have dependents (other than your
children or spouse) who live with you and
who receive more than half of their
support from you between July 1, 2020
June 30, 2021?
Yes No If yes, please list their names and relationship to you:
Will you receive money from any of the following between 7/1/2020 6/30/2021?
Income from working?
Yes No
Significant other?
Yes No
Financial aid and/or scholarships?
Yes No
SNAP (Food Stamps)?
Yes No
Women, Infants and Children (WIC) Assistance?
Yes No
Social Security Benefits?
Yes No
Housing Assistance / Benefits (including Section 8 / low income housing)?
Yes No
Medical Assistance (AHCCCS)
Yes No
Supplemental Security Income (SSI)?
Yes No
Welfare (including TANF)?
Yes No
Other: _____________________________________________________________
(Unemployment, Disability, etc.)
Yes No
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's Signature and Date How do I create a digital signature with Adobe?
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
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