California Community Colleges 2016-17 Board Of Governors Fee Waiver Application Form (Page 3 of 4) in pdf

METHOD B ENROLLMENT FEE WAIVER

15. DEPENDENT STUDENT: How many persons are in your parent(s)/RDP household? (Include yourself, your parent(s)/RDP, and anyone who

lives with your parent(s)/RDP and receives more than 50% of their support from your parents/RDP, now and through June 30, 2017.)

_________

16. INDEPENDENT STUDENT: How many persons are in your household? (Include yourself, your spouse/RDP, and anyone who lives with you

and receives more than 50% of their support from you, now and through June 30, 2017.)

_________

17. 2015 Income Information

(Dependent students should not include their own

DEPENDENT STUDENT:

INDEPENDENT STUDENT:

Income information for Q 17, a and b below.)

PARENT(S)/RDP

STUDENT (& SPOUSE’S/

Adjusted Gross Income (If 2015 U.S. Income Tax

INCOME ONLY

RDP) INCOME

Return was filed, enter the amount from Form 1040,

line 37; 1040A, line 21; 1040EZ, line 4).

$______________

$__________________

All other income (Include ALL money received in

2015 that is not included in line (a) above (such as

Disability, child support, military living allowance,

Workman’s Compensation, untaxed pensions.)

$______________

$__________________

TOTAL Income for 2015 (Sum of a + b)

$______________

$__________________

The Financial Aid Office will review your income and let you know if you qualify for an ENROLLMENT FEE WAIVER under Method B.

Submit application and documentation to the financial aid office.

If you do not qualify using Method A or Method B, you should file a FAFSA (for U.S. citizens or eligible non-citizens) or the California

Dream Application (for undocumented AB 540 students). The FAFSA is available at and the Dream Application is available

at https://dream.csac.ca.gov/. Contact the Financial Aid Office for more information.

SPECIAL CLASSIFICATIONS ENROLLMENT Fee Waivers

18. Do you have certification from the CA Department of Veterans Affairs that you are eligible for a dependent's fee waiver?

Submit certification.

Yes No

19. Do you have certification from the National Guard Adjutant General that you are eligible for a dependent's fee waiver?

Submit certification.

Yes No

20. Are you eligible as a recipient of the Congressional Medal of Honor or as a child of a recipient?

Submit documentation from the Department of Veterans Affairs.

Yes No

21. Are you eligible as a dependent of a victim of the September 11, 2001, terrorist attack?

Submit documentation from the CA Victim Compensation and Government Claims Board.

Yes No

22. Are you eligible as a dependent of a deceased law enforcement/fire suppression personnel killed in the line of duty?

Submit documentation from the public agency employer of record.

Yes No



If you answered "Yes" to any of the questions from 18-22, you are eligible for an ENROLLMENT FEE WAIVER and perhaps other fee waivers or

adjustments. Sign the Certification below. Submit application and documentation to the financial aid office. Contact the Financial Aid Office if you

have questions.

CERTIFICATION FOR ALL APPLICANTS: READ THIS STATEMENT AND SIGN BELOW

I hereby swear or affirm, under penalty of perjury, that all information on this form is true and complete to the best of my knowledge. If asked by an authorized

official, I agree to provide proof of this information, which may include a copy of my and my spouse/registered domestic partner and/or my

parent's/registered domestic partner’s 2015 U.S. Income Tax Return(s). I also realize that any false statement or failure to give proof when asked may be cause

for the denial, reduction, withdrawal, and/or repayment of my waiver. I authorize release of information regarding this application between the college, the college

district, and the Chancellor's Office of the California Community Colleges.

I understand the following information (please check each box):

Federal and state financial aid programs are available to help with college costs (including enrollment fees, books & supplies, transportation and room and



board expenses). By completing the FAFSA or the California Dream Application, additional financial assistance may be available in the form of Cal Grants, Pell

and other grants, work study and other aid.



I may apply for and receive financial assistance if I am enrolled, either full time or part time, in an eligible program of study (certificate, associate degree or

transfer).

Financial aid program information and application assistance is available in the college financial aid office.



Applicant’s Signature

Date

Parent Signature (Dependent Students Only)

Date