(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-109-HOME21 20200416
Youth Housing Information (to be completed by a Youth Housing Official- Please Print)
Youth Housing Official Full Name
Phone Number
Mailing Address
Affiliation (Please check one)
McKinney-Vento School District
Director or designee of an HUD-
funded shelter
Director or designee of an RHYA-
funded shelter
According to the C
ollege Cost Reduction and Access Act (Public Law 110-84), I, the official listed above, am
authorized to verify the above student’s living situation. Should you have more questions or need more
information about this student, please contact our office at the number listed above.
I confirm the f
ollowing about the student listed above (please check one):
The Student is… Definition
An unaccompanied homeless youth
after July 1, 2019.
After July 1, 2019, the student was living in a homeless situation, as
defined by Section 725 of the McKinney-Vento Act, and was not in
the physical custody of a parent or guardian.
An unaccompanied self-supporting
youth at risk of homelessness after
July 1, 2019.
After July 1, 2019, the student was not in the physical custody of a
parent or guardian, provides for his or her own living expenses
entirely on his or her own, and is at risk of losing his or her housing.
I certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving false or misleading
information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent to prison or both. I hereby
provide consent for the use of electronic records and signatures on all financial aid documents. I understand that if I choose to sign
electronically, my electronic signature constitutes a binding contract and may not be denied legal effect, validity, or enforceability
solely because it is in electronic form or because an electronic signature or electronic record was used in its formation.
Student Signature and Date How do I create a digital signature with Adobe?
Youth Housing Official Signature and Date
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
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