Pell Supplemental Information Form 2020-2021
Dr. H.A. Miller Student Services Center | 417 Schepps Blvd. | Clovis, NM 88101
Phone (575)769-4060 | Fax (575)769-4027
Name ______________________________________ CCC ID___________________________
Social Security Number _____________________________ Date of Birth _____________________
Address _________________________________________City ______________ State_________ Zip________
Phone Number____________________________ Email Address__________________________________
Name ________________________Relationship _______________________ Phone _____________________
Address _________________________________________City ______________ State_________ Zip________
Wereyouoranymemberofyourhouseholdactivedutymilitaryduring2018?
YesNo
If Yes, please complete BAS form
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, 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.
By signing this statement, you certify that all of the above information is complete and correct. Warning: If you purposely give false
or misleading information you may be fined, sentenced to jail, or both.
Student Signature ___________________________________________________ Date______________________________
Student Information
Emergency Contact
Military Status
Deferment Authorization A
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SIGNATURE REQUIRED
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signature
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