ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
email: financialaid@icc.edu
Rev. March 14, 2019
Student Aid Eligibility Worksheet Drug Conviction 2019-2020
Student Name
ICC Student ID #
Complete this worksheet to determine if you are eligible for federal student aid.
1. Have you ever received federal student aid? Answer “NO” if you have never received federal student grants,
federal student loans, or federal work-study. You should also answer “NO” if you have never attended college.
_____ NO - Please sign and date the end of this form. You are done.
_____ YES - Go to question 2.
2. Have you been convicted for the possession or sale of illegal drugs for an offense that occurred while you
were receiving federal student aid (grants, loans, and/or work-study)? Only include federal and state
convictions. Do not count any convictions that have been removed from your record or that occurred before you
turned age 18, unless you were tried as an adult.
_____ NO - Please sign and date the end of this form. You are done.
_____ YES - Go to question 3.
3. Did the offense for possession or sale of illegal drugs occur during a period of enrollment for which you
were receiving federal student aid (grants, loans, and/or work-study)?
_____ NO - Please sign and date the end of this form. You are done.
_____ YES - Go to question 4.
4. Have you completed an acceptable drug rehabilitation program since your conviction? An acceptable drug
rehabilitation program must include at least two unannounced drug tests, and:
a. be qualified to receive funds from a federal, state, or local government or from a federal or state-licensed
insurance company; or
b. be administered or recognized by a federal, state, or local government agency or court, or a federal or
state-licensed hospital, health clinic or medical doctor.
_____ YES - Please sign and date the end of this form. You are done.
_____ NO - Go to question 5.
5. Do you have more than two convictions for possessing illegal drugs? Only count convictions for offenses that
occurred during a period of enrollment for which you were receiving federal student aid (grants, loans, and/or
work-study).
_____ YES - Please sign and date the end of this form. You are done.
_____ NO - Go to question 6.
(over)
Rev. March 14, 2019
6. Do you have more than one conviction for selling illegal drugs? Only count convictions for offenses that
occurred during a period of enrollment for which you were receiving federal student aid (grants, loans and/or
work-study).
_____ YES - Please sign and date the end of this form. You are done.
_____ NO - Go to question 7.
7. Write the date of your last conviction for possessing illegal drugs here: ______________________
If you have no convictions for possessing drugs, skip to question 9 on this worksheet.
8. If you have only one conviction for possessing drugs, add one year to the date in question 7, and write that date
here: ______________________________
If you have two convictions for possessing drugs, add two years to the date in question 7, and write that date here:
______________________________
9. Write the date of your last conviction for selling illegal drugs here: _______________________
If you have no convictions for selling drugs, skip to questions 11 on this worksheet.
10. If you have only one conviction for selling drugs, add two years to the date in questions 9, and write that date here:
______________________________
11. Look at the dates you wrote in questions 8 and 10. The later of the two dates listed below is your eligibility date.
If there is only one date, copy that date here: ____________________________
If there are two dates, write the later one here: ___________________________
I certify that the above statement is true and complete to the
best of my knowledge. I also understand that falsification of
information on my part may result in the loss of Financial Aid.
It is the policy of this College that no person, on the basis of race, color, religion, gender, national origin, age, disability,
sexual orientation, or veteran’s status, shall be discriminated against in employment, in educational programs and
activities, or in admission. Inquiries and complaints may be addressed to the Compliance Officer, Diversity Department.
Student Signature
Date
FEDERAL WARNING: If you
purposely give false or misleading
information on this worksheet, you may
be fined, be sentenced to jail, or both.