Student Status Financial Aid Verification Form

Student Status and Financial Aid Verification

TO:

RE:

___________________________

Name

___

Social Security Number

FROM:

Thank you for your prompt response.

All information is confidential. Please contact

at (

)

if you have any questions.

Permission for Release of Information (this section to be completed by student)

NOTE: You do not have to sign this form if either the requesting organization or the organization supplying the

information is left blank. I hereby authorize the release of the requested information. Information obtained under this

consent is limited to information that is no older than 12 months. There are circumstances which would require the

owner to verify information that is up to five years old, which would be authorized by me on a separate consent, attached

to a copy of this consent.

Signature

Date

Verification (this section to be completed by financial aid provider and/or educational institution)

Please complete all information requested below. Write N/A if not applicable.

1. Student currently attends school (please circle one):

Full Time

Part Time

2. If full time, the date the student enrolled as such:

_____/_____/_____

3. Expected date of graduation:

_____/_____/_____

4. Does student attend summer session?

Yes

No

5. Is student a participant in a program funded under the Job Training Partnership Act or Workforce Investment Act,

or a similar program?

Yes

No

6. Total financial assistance including scholarships, grants, etc. (public or private, excluding student loans) received:

Source

Amount

Beginning Date

Ending Date

Scholarships

$

Grants

$

Work Study

$

Cost of Tuition and Required Fees

$

I hereby certify that the statements above are true and complete to the best of my knowledge.

Signature

Date

Print Name

Title

Address

Email Address

City, State Zip

Phone

Penalties for Misusing this Content: Title 18, Section 1001 of the U.S. Code states that a person is guilty of a felony for knowingly and willingly making false or fraudulent

statements to any department of the United States Government. HUD and any owner (or any employee of HUD or the owner) may be subject to penalties for unauthorized

disclosures or improper uses of information collected based on the consent form. Use of the information collected based on this verification form is restricted to the purposes cited

above. Any person who knowingly or willingly requests, obtains, or discloses any information under false pretenses concerning an applicant or participant may be subject to a

misdemeanor and fined not more than $5,000. Any applicant or participant affected by negligent disclosure of information may bring civil action for damages and seek other relief,

as may be appropriate, against the officer or employee of HUD or the owner responsible for the unauthorized disclosure or improper use. Penalty provisions for misusing the social

security number are contained in the Social Security act at 208 (a) (6), (7) and (8). Violations of these provisions are cited as violations of 42 USC 408 (a), (6), (7) and (8).

Student Status and Financial Aid Verification

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2016.09