Fillable Unusual Enrollment Verification Form 2020 2021 (College of St. Francis)

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Unusual Enrollment Verification Form 2020 2021 (College of St. Francis)

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Unusual Enrollment Verification Form
2020 – 2021
Student’s Name ___________________________________USF ID or SSN:______________________________
Based on information provided by the U.S. Department of Education and your academic transcripts, you are required to answer
questions regarding your academic history. This verification is to determine if you receive academic credit for attendance at
each of the institution attended during the last four academic years. Complete the items below and respond to each academic
year question. If you need additional space, use the reverse side of this document.
1. In 2016-2017, I attended: ______________________________________________
(Name of Institution)
I received academic credit at this institution? YES / NO ( If no, complete the explanation statement.)
I did not receive academic credit at this institution for the following reason:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
2. In 2017-2018, I attended: ______________________________________________
(Name of Institution)
I received academic credit at this institution? YES / NO (If no, complete the explanation statement.)
I did not receive academic credit at this institution for the following reason:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
3. In 2018-2019, I attended: ______________________________________________
(Name of Institution)
I received academic credit at this institution? YES / NO (If no, complete the explanation statement.)
I did not receive academic credit at this institution for the following reason:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
4. In 2019-2020, I attended: _______________________________________________
(Name of Institution)
I received academic credit at this institution? YES / NO (If no, complete the explanation statement.)
I did not receive academic credit at this institution for the following reason:
For each institution listed above, where you did not receive academic credit, attach documentation to support the
explanation. Examples of documentation may be but are not limited to a) statement from a Physician or other medical
professional, b) statement or documents from an academic advisor or faculty member, c) military orders describing
deployment, and/or d) personal statement describing the situation in detail.
Please answer the following question: Did you knowingly enroll for classes and not complete them for the purpose of
receiving a refund from your Federal Pell Grant? YES / NO (Please circle one)
Student Statement: I, ___________________________________, hereby swear the information I have provided is
true and correct. I fully realize that fraudulently obtaining federal financial assistance is punishable by fines,
imprisonment or both. I verify that the information provided above is true and accurate.
___________________________________________________ ___________________________________
Student Signature Date
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Unusual Enrollment Verification Form 2020 2021 (College of St. Francis)

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Completed 22 July 2020

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