WARNING: If you purposely give false or misleading information, you may be fined, sent to prison or both.
FA20CSSE/FA20CPSE
OFFICE OF STUDENT FINANCIAL AID
ROBESON COMMUNITY COLLEGE
Student Center Building 13
PO Box 1420
Lumberton, NC 28359
T 910.272.3352 Email: finaid@robeson.edu
F 910.272.3314 Website: https://www.robeson.edu/fa/
2020-2021 Verification of
Separation Status
Student’s Name: ____________________________________StudentID____________________
Address: _______________________________________City/State/Zip____________________
Phone #: _______________________________Email: ________________________________
This document needs to be completed by: Separated Student Separated Parent
You must sign this form in the presence of a notary. The Financial Aid Staff may not provide notarization.
I, (print your full name) ______________________________________________, am separated from my spouse,
(print spouse’s full name) , as of .
We are no longer residing together and plan to obtain a divorce.
My address is: Street Apt _______________
City State Zip _______________
My spouse’s address is: Street Apt _______________
City State Zip _______________
Check box if spouse’s address is unknown. If box is checked, please provide a typed letter detailing the
situation of why the spouse’s address is unknown.
NOTE: You must submit a letter on letterhead from one of the following persons or organizations:
For military and their dependents: A letter is required from the Family Services Office, the Unit
Chaplain, or the Unit S-1 Personnel Office.
For civilians: A Letter is required from a clergyperson, an attorney, or your employer.
Separated Person's Signature _______________________________ Date: ___________________
click to sign
signature
click to edit
WARNING: If you purposely give false or misleading information, you may be fined, sent to prison or both.
FA20CSSE/FA20CPSE
OFFICE OF STUDENT FINANCIAL AID
ROBESON COMMUNITY COLLEGE
Student Center Building 13
PO Box 1420
Lumberton, NC 28359
T 910.272.3352 Email: finaid@robeson.edu
F 910.272.3314 Website: https://www.robeson.edu/fa/
2020-2021 Verification of
Separation Status
Notary’s Certificate of Acknowledgement
State of
County of
On (Date) , before me (Notary’s Name), ,
personally appeared (Printed name of signer),
and proved to me on the basis of satisfactory evidence of identification (indicated in
Section A above) to be the above-named person who signed the foregoing
instrument.
_________________________________ _____________
NOTARY SIGNATURE (If applicable) DATE
Notary Stamp or Seal
My commission Expires:
________________________
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