Dr. H.A. Miller Student Services Center
417 Schepps Blvd., Clovis, NM 88101
Ph. (575) 769-4060 * Fax (575) 769-4027
Pell Supplemental Information
2019-2020
Student Information
CCC ID Social Security Number Name
Street Address City State Zip
Phone Number Email Address Date of Birth
Reference/Emergency Contact
List someone that will always be able to contact you. Must have a complete phone number and address.
Name Address Telephone Relationship
Military Status
Were you or any member of your household active duty military during 2017? Yes No
Deferment Authorization Agreement (DAA)
Students may cancel this DAA at any time in writing.
Please INITIAL that you understand the following:
I authorize CCC to credit any financial aid I receive to my student account to pay for tuition,
fees, bookstore charges and any other charges I may incur. I understand that all charges will
automatically be deducted from my financial aid. If my financial aid is canceled for any reason
or if my financial aid does not cover all my charges, I will be responsible for paying, in full, any
charges owed to CCC. I further understand that if I fail to pay
these charges by midterm of the
semester I incurred them, a hold may be placed on my registration and my academic records.
I will also be responsible for paying all costs necessary for collections including legal costs
and attorney fees plus interest on my account balance at the statutory rate. Furthermore, I
understand that if I do not authorize this deferment and I do not pay my charges by the
scheduled deadlines my classes may be dropped.
SIGNATURE REQUIRED
By signing this statement you certify that all of the information reported on it, is complete and correct. Warning: If you purposely give false or
misleading information on this worksheet, you may be fined, sentenced to jail, or both.
Student Signature: Date:
Revised 9-28-2017
click to sign
signature
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