Minnesota State Grant Questionnaire Template

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MINNESOTA STATE GRANT
Academic Year 2015–2016
QUESTIONNAIRE
RETURN FORM:
BY MAIL TO:
Office of Student Finance
20 Fraser Hall
DIRECTIONS
106 Pleasant St. SE
You must sign this form on the back.
Minneapolis, MN 55455
IN PERSON ON CAMPUS AT:
One Stop needs further information from you before your financial
One Stop Student Services
aid eligibility can be determined. Your aid may not be processed until
333 Science Teaching & Student Services
130 West Bank Skyway
this form is completed, signed, and returned along with all requested
130 Coffey Hall
documentation.
Questions?
Phone: 612-624-1111
TTY (hearing impaired): 612-626-0701
Email: onestop@umn.edu
To ensure privacy online, open in Adobe Reader (free at ). Please add the required signature(s) in blue or black ink.
SECTION A. Student information
Name (last, first, middle initial)
Birthdate (mm/dd/yyyy)
University ID
Current mailing address (street, apartment or PO box number, city, state, ZIP code, country)
Phone (include area code)
SECTION B. Reciprocity information (all students must complete)
Please note that students receiving reciprocity are not eligible for the Minnesota State Grant.
Will you be receiving Wisconsin, South Dakota, North Dakota, or Michigan reciprocity in 2015–2016?
yes
no
Will you participate in the Midwest Student Exchange Program (MSEP) in 2015–2016?
yes
no
If you answered ‘yes’ to at least one of the above: Please skip to Section G, sign, and return this form to One Stop. You are
not eligible for the Minnesota State Grant. If you answered ‘no’ to both of the above: Please proceed to Section C.
SECTION C. Educational history (all students must complete)
1. By July 1, 2015, will you have graduated from high school?
yes
no
Name of high school
City
State
Date of graduation (mm/dd/yyyy)
2. By July 1, 2015, will you have obtained a GED in Minnesota? A GED is a certificate granted to people who did not graduate from high school,
but passed a high school equivalency test.
yes
no
Date of GED ______________
State of GED _____________.
3. List all universities, colleges, and business/technical institutions you have attended beyond high school. Please include the University of
Minnesota and military service. We will request your transcript from any school listed if we do not already have it on file.
Name of school
Dates of attendance (mm/yyyy to mm/yyyy)
4. Do you have a four-year undergraduate degree?
yes
no
If yes, awarded by __________________________. When? __________.
SECTION D. Verification of parents’ MN residency (all dependent and independent students must complete)
1. Have your parents ever lived in the state of Minnesota?
yes
no
If yes, please indicate the dates: from _________________ to _________________.
2. Parent’s address at the time your 2015–2016 FAFSA was completed.
Street address
City
State
ZIP code
3. Have you, your parent, or your spouse been relocated to Minnesota with refugee status from another country?
If yes, enter name of country: ______________________________________________________________________________________
—Please continue on page 2—
To request copies of this form in an alternative format, please call a Disability Resource Center
*FA679*
liaison at 612-625-9578. The University of Minnesota is an equal opportunity employer and
educator. This form is printed on paper made from no less than 20 percent post-consumer waste.
FA679—Page 1 of 2 12/14
Please recycle.

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