Dr. H.A. Miller Student Services Center
417 Schepps Blvd., Clovis, NM 88101
Ph. (575) 769-4060 * Fax (575) 769-4027
Rejected ISIR Signature
2019-2020
STUDENT INFORMATION
CCC ID Social Security Number Name
Street Address City State Zip
Phone Number Email Address Date of Birth
Signature Page Information
PLEASE READ, SIGN AND DATE
If you are the student, by signing this application you certify that you
1. will use federal and/or state student financial aid only to pay the cost of attending an institution of higher
education,
2. are not in default on a federal student loan or have made satisfactory arrangements to repay it,
3. do not owe money back on a federal student grant or have made satisfactory arrangements to repay it,
4. will notify your college if you default on a federal student loan, and
5. will not receive a Federal Pell Grant from more than one college for the same period of time.
If you are the parent or the student, by signing this application, you certify that all of the information you provided is
true
and complete to the best of your knowledge and you agree, if asked, to provide information that will verify the
accuracy of your completed form. This information may include U.S. or state income tax forms that you filed or are
required to file. Also, you certify that you understand that the Secretary of Education has the authority to verify
information reported on this application with the Internal Revenue Service and other Federal agencies. If you
sign any
document related to the federal student aid programs electronically using a personal identification number
(PIN), you
certify that you are the person identified by the PIN and have not disclosed that PIN to anyone else.
Everyone whose information is given on the FAFSA should sign below. The student (and at least one parent, if
parent
information is given) MUST sign below.
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, be sentenced to jail, or both.
Student Printed Name:
Student Signature:
Parent Printed Name:
Parent Signature:
Date:
Date:
Revised 03-12-2019
FOR OFFICE USE ONLY:
Corrections
SENT:
RCVD:
TRANS #:
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