________________________________________ _________________________________
________________________________________ _________________________________
Waycross Campus (912) 287-6584
Jesup (912) 427-5800
Alma (912) 632-0951
Camden (912) 510-3327
Hazlehurst (912) 379-0041
Baxley (912) 367-1700
Golden Isles (912) 262-4999
Website: www.coastalpines.edu
Missing Signature Page
Form: PSGN21/SSGN21
Aid Year: 2020-2021
Read, Sign, and Date
If you are the student, by signing this application you certify that you (1) will use federal and/or state student
financial aid only to pay the cost of attending an institution of higher education, (2) are not in default on a federal
student loan or have made satisfactory arrangements to repay it, (3) do not owe money back on a federal student
grant or have made satisfactory arrangements to repay it, (4) will notify your college if you default on a federal
student loan and (5) will not receive a Federal PELL Grant from more than one school for the same period of time.
If you are the parent or the student, by signing this application you certify that all of the information you provide is
true and complete to the best of your knowledge and you agree, if asked, to provide information that will verify the
accuracy of your completed form. This information may include U.S. or state income tax forms that you filed or are
required to file. Also, you certify that you understand that the Secretary of Education has the authority to verify
information reported on this application with the Internal Revenue Service and other federal agencies. If you
sign any document related to the federal student aid programs electronically using an FSA ID (a username and
password), you certify that you are the person identified by the FSA ID and have not disclosed that FSA ID to
anyone else. If you purposely give false or misleading information, you may be fined $20,000, sent to prison, or
both.
Student Signature Date
Parent Signature Date
Please "Print or Type" your Name and Student ID Number below so that
we can identify your signature when the form is return to the Office of Financial Aid.
Printed Student Name Student ID Number
As set forth in the student catalog, Coastal Pines Technical College (CPTC) does not discriminate on the basis of race, color, creed, national or
ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in
those special circumstances permitted or mandated by law). The following persons have been designated to coordinate the College’s
implementation of non-discrimination policies: Katrina Howard, Title IX Coordinator, Jesup Campus, Office 132, khoward@coastalpines.edu ,
912.427.5876; Cynthia Linder, Office 1439, Title IX Coordinator, Waycross Campus, clinder@coastalpines.edu , 912.287.4098; and Cathy
Montgomery, ADA/Section 504 Coordinator, Golden Isles Campus, Office 1141, cmontgomery@coastalpines.edu , 912.262.9995.
2021 Missing Signature Page
click to sign
signature
click to edit
![]()
click to sign
signature
click to edit
![]()
