Fillable Renewal Application (Alabama Commission on Higher Education)

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Renewal Application (Alabama Commission on Higher Education)

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BROWSE ALABAMA COMMISSION ON HIGHER EDUCATION FORMS

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ALABAMA COMMISSION ON HIGHER EDUCATION
Grants and Scholarships Department
P.O. Box 302000
Montgomery AL 36130-2000
RENEWAL APPLICATION AND CERTIFICATION
OF CONTINUED ELIGIBILITY UNDER THE POLICE OFFICER’S AND
FIREFIGHTER’S SURVIVORS EDUCATIONAL ASSISTANCE PROGRAM
Name of Applicant:
(Last) (First) (Middle)
Social Security Number: ___ ___ ___ - ___ ___ - ___ ___ ___ ___ Email Address:
Mailing Address:
(Rural Route or Street and Number)
(City) (State) (Zip Code)
Home Telephone: ________________ Cellphone: ___________________ Work Telephone:
All of the information provided on my original application and certification of eligibility for participation
in the Police Officer’s and Firefighter’s Survivors Educational Assistance Program and submitted to the
Alabama Commission on Higher Education is: (Check one)
_____ Unchanged and correct.
_____ Changed because I plan to attend a new institution as listed below.
_____ Changed because I am a spouse who has remarried.
Transcript(s) must be attached: (Check one)
______ I attended only one institution during the current academic year and the
transcript is attached.
______ I attended more than one institution during the current academic year and
transcripts reflecting all course work are attached.
______ I did not attend the current academic year and transcript(s) from previous
enrollment(s) reflecting all course work are attached.
I hereby certify that I have been accepted for enrollment, or am eligible for continued enrollment, as a student
in good academic standing at the institution noted below. I also acknowledge that the statements and
attachments included with this renewal application for continued eligibility for benefits under The Code of
Alabama 1975, Sections 36-21-100 through 36-21-105 are, to my knowledge, true and correct.
_____________________________________ _____________________________________
Institution Signature of Applicant Date
Terms Aid Is Requested (Please check) Expected Graduation Date
______ Fall (Month/Year)
______ Spring
______ Summer
ACHE Date Stamp
THE APPLICANT IS HEREBY CERTIFIED as qualified under the provisions of The Code of Alabama 1975,
Sections 36-21-100 through 36-21-105 and eligible for continued educational assistance
for undergraduate study at the postsecondary educational institution listed by the applicant.
__________________________________
Date Signature of Chair of the Tuition Eligibility Board
USE OF SOCIAL SECURITY NUMBER
Section 7(a) of the Privacy Act of 1974 (5 U.S.C. 522A) requires that when any Federal, State, or local
government agency requests an individual to disclose his/her Social Security account number, that
individual must also be advised whether that disclosure is mandatory or voluntary, by what statutory or
other authority the number is solicited, and what uses will be made of it.
Accordingly, applicants are advised that disclosure of their Social Security Account Number (SSAN) is required
as a condition for participation in the Police Officer’s and Firefighter’s Survivors Educational Assistance
Program in view of the practical administrative difficulties which the Program would encounter in
maintaining adequate program records without the continued use of the SSAN.
The SSAN will be used to verify the identity of the applicant and as an account number (identifier)
throughout the life of the scholarship in order to record necessary data accurately. As an identifier, the SSAN
is used in such Program activities as determining Program eligibility, certifying school attendance, making
and verifying scholarship payments, and maintaining records of scholarship payments. Authority for
requiring the disclosure of an applicant’s SSAN is in Section 7(a)(2) of the Privacy Act, which provides that an
agency may require disclosure of an individual SSAN as a condition for the granting of a right, benefit, or
privilege provided by law.
This form must be completed and returned to:
Alabama Commission on Higher Education
Grants and Scholarships Department
P.O. Box 302000
Montgomery AL 36130-2000
Please attach all transcripts
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Renewal Application (Alabama Commission on Higher Education)

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Completed 29 July 2020

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