Form 5 - Fverhd Financial Aid - 2016-2017
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1
22016-2017
FORM 5 - FVERHD
Financial Aid Office
5150 N. Maple Avenue, M/S JA 64
Fresno, CA 93740-8026
Phone: (559) 278-2182
Fax: (559) 278-4833
- DEPENDENT STUDENT -
Household Members and In College
STUDENT ID
LAST NAME
FIRST NAME
PHONE NUMBER
(with area code)
PLEASE PRINT IN BLACK INK
1. At the start of the FALL 2016 SPRING 2017 Semester, student will be living:
With parent(s)
On Campus
Off Campus
List all the people in the household, and the requested information below:
(See instructions on page 2)
Will be enrolled at least
Relationship
College name if attending at least
Full Name
Age
half-time
to Student
½ time in 2016-2017
Self
Fresno State
1.
Yes
2.
Yes
3.
Yes
4.
Yes
5.
Yes
6.
Yes
7.
Yes
8.
Yes
9.
Yes
10.
Yes
*List additional household members on a separate sheet of paper.
**NOTE:
Additional documentation may be required if there is reason to believe information reported is inaccurate.
CERTIFICATION & SIGNATURE(S)
By signing this form, I (we) certify that all the information reported on it is complete and correct.
Student Signature
Date
Parent 1 Signature
Parent 2 Signature
WARNING:
If you purposely give false or misleading information you may be fined, be sentenced to jail, or both.
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