Please read, sign and date.
By signing this form you agree, if asked, to provide information that will verify the accuracy of this completed
form. This information may include your U.S. or state income tax forms, divorce decree, utility bills, etc. Also,
you certify that you understand that the Secretary of Education has the authority to verify information
reported on this form with the Internal Revenue Service and other federal agencies. If you purposely give
false or misleading information, you may be fined $20,000, sent to prison, or both.
Student's Signature: ____________________________________________ Date: _____________________________
FAA Comments :
University ID (or Social Security Number)
Full Name Age
Enrolled at Least Half-
Time (Yes or No)
Southeastern LA Univ.
Student's Family Information
List below the people in your household. Include:
• Yourself and your spouse if you are married. (Do not include your spouse if you are separated)
• Your children or your spouse's children, if you will provide more than half of their support from July 1, 2019,
through June 30, 2020, even if the children do not live with you.
• Other people if they now live with you and you or your spouse provides more than half of their support and will
continue to provide more than half of their support through June 30, 2020.
For any household member who will be enrolled at least half-time in a degree, diploma, or certificate program at an
eligible postsecondary educational institution any time between July 1, 2019 and June 30, 2020, include the name of
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