Rejected ISIR Signature Page 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__________________________________
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 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 FAFSA form. This information may include federal or state income tax forms that you filed or
are required to file. Additionally, 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.
The student, and at least one parent if dependent on the FAFSA, MUST sign below.
By signing this 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 Printed Name: ___________________________
Student Signature: ______________________________ Date: ________________
Parent Printed Name: ____________________________
Parent Signature: _______________________________ Date: ________________
For Office Use only
Correction Sent: Correction Received: Transaction:
Student Information
Si
nature Pa
e Information
SIGNATURE REQUIRED
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