Lorain County Community College Financial Services 1005 N. Abbe Rd, Elyria, OH 44035 Phone: 440-366-4034
Parent FAFSA Refusal Form
2020-21 Financial Aid Year
Last Name First Name Middle Initial
LCCC Student ID #
Federal regulations give schools the authority to allow a student to borrow a Federal Direct Unsubsidized Loan when the student’s parent(s) have
ended all financial support and have refused to complete and sign a Free Application for Federal Student Aid (FAFSA). Students who request
consideration for this type of loan should read the information on this form and have one parent complete and sign this form. Note: this form does
not allow a student to apply for financial aid as an independent student. Completion and submission of this form only allows students to request an
unsubsidized loan subject to the limits for dependent students. No other federal or state financial aid will be available.
Although LCCC Financial Services may waive the requirement for parent income and asset information on the FAFSA with submission of this form,
the student must complete and submit a FAFSA that includes all of the required student information and certifications.
Section A – Parent Information (to be completed by at least one biological or adoptive parent):
I attest to the following:
I have stopped providing financial support to the student named above (including payment of educational costs, as well as all
other cash and non-cash support such as room, meals, utilities, insurance, etc.).
Date support ended:
I will not provide support to the student in the future.
I refuse to complete the parental section of the Free Application for Federal Student Aid (FAFSA).
Section B: Certification
Each person signing this form certifies that all of the information reported is complete and accurate. Warning: If you purposely give false or
misleading information on this form, you may be fined, sentenced to jail, or both. Electronic signatures will not be accepted.
Student signature: Date:
Parent signature: Date:
When all required documents have been gathered, you may submit your information by: a) mail to the address below; b) fax to 440-366-4634 or; c)
deliver to Financial Services, First Floor, Bass Library during open hours. Please note: Your request may not be approved nor result in an increase of
your financial aid eligibility. You will be notified of the result of your request via email sent to your official LCCC email address.