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2016-2017 DOCUMENT OF NON-PARENTAL SUPPORT

EXCLUSION OF PARENT INFORMATION ON FAFSA

Based on the results of your Free Application for Federal Student Aid (FAFSA), you did not report information about your parent(s). You indicated that

your parent(s) are not financially supporting you, nor will be supporting you financially in the future.

NAME _____________________________________________________________________________

Last

First

Student ID Number

ADDRESS ________________________________________________________________________________________________________________

Street Address

Apt. #

City

State

Zip Code

DATE OF BIRTH __________________________________________________EMAIL ADDRESS _____________________________________________

HOME PHONE NUMBER ____________________________________________ALTERNATE/CELL-PHONE NUMBER ________________________________

(Including area code)

If ALL of the following apply, please complete this form:

You have contact (regardless of how much) with your parent(s) but do not live with them.

•

You do not receive ANY support from your parent(s); this includes insurance coverage, auto payments or support of any kind.

•

Your parent(s) have refused to complete the parent portion of the 2016-2017 FAFSA.

•

PARENT CERTIFICATION

Your parent(s) are required to complete the Parent Certification below:

Parent 1 Name _________________________________________________________________

Last

First

Parent 2 Name _________________________________________________________________

Last

First

All boxes must be checked by parent(s) before this form is processed

I certify that my child does not live with me.

I refuse to complete the parent portion of the 2016-2017 FAFSA.

I understand that by completing this form I cannot apply for a Federal parent PLUS Loan.

I certify that I do not provide any support to my child. Date I stopped supplying support (month/year): _______________________________

Notice: Students completing this form are ONLY eligible for the Federal Direct Unsubsidized Loan at the dependent student loan limit. Students

completing this form are not eligible for any need-based aid, including federal, state and university funds.

Certification Statement and Signature

By signing below, I/we certify that the information provided is true and accurate. I/we understand that any false statement or misrepresentation may

be cause for reduction and/or repayment of federal, state, or institutional financial aid. I/we agree to provide additional proof of information provided

on this form.

Student’s Signature ____________________________________________________Date _____________________________________

Parent 1 Signature _____________________________________________________Date _____________________________________

Parent 2 Signature _____________________________________________________Date _____________________________________

Notary Signature _____________________________________ Commission Expires ___________________Date ____________________

(Seal Required)

Office of Financial Aid

Grace E. Harris Hall Student Service Center

1015 Floyd Ave., 1st Floor

P.O. Box 843026

Richmond, VA 23284-2520

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