Cal Grant GPA Verification Form
DEADLINE: SEPTEMBER 2, 2015
Cal Grants for students attending
DO NOT SEND ACADEMIC TRANSCRIPTS
a Community College during the
2015-16 Academic Year
( SEE BACK OF FORM FOR INSTRUCTIONS)
TO BE FILLED OUT BY STUDENT
Please print clearly using black or blue ink).
Your Social Security number:
2. Month/year of
Re-enter your Social Security
Your name — last, first, middle initial, as it is listed on your Social Security card and FAFSA:
Your Last Name
Your First Name
Your date of birth:
5. Telephone number:
Your permanent mailing address:
Number and Street
CSAC USE ONLY
Your E-mail address, if available:
Fill in bubble if you are submitting a SAT, ACT or GED test score instead of a GPA.
Attach your applicable test score to this form, transcripts will not be accepted. You do not have to have your school fill out the FOR SCHOOL USE ONLY section
STUDENT CERTIFICATION: I have read the instructions and information accompanying this form. I understand that this Cal Grant GPA
Verification Form is used to determine Cal Grant eligibility and the GPA must be calculated as described on the attached GPA Calcula-
tion Instruction sheet. The information I have completed is true to the best of my knowledge, and I understand that it is illegal to report
false or misleading information. I understand that without a valid Social Security number and signature, this form will not be considered.
I declare under penalty of perjury under the laws of the State of California that the foregoing is true and correct.
FOR SCHOOL USE ONLY (High schools MUST be fully accredited by the Western Association of Schools and Colleges [WASC] or an
equivalent regional accreditation agency to certify a Cal Grant high school GPA)
GPA IS BASED ON HIGH SCHOOL COURSEWORK?
GPA VERIFIER’S SCHOOL CODE:
VERIFIED STUDENT GPA:
CALIFORNIA COMMUNITY COLLEGE REESTABLISHED GPA?
The signature of the high school or college official certifies, under penalty of perjury, that the GPA is calculated as described on the attached GPA
Calculation Instruction sheet. The signature of a high school official also certifies that his or her high school is fully accredited by the WASC or other
regional accrediting agency, or has a UC-approved course list as required by California regulations. I declare under penalty of perjury under the
laws of the State of California that the foregoing is true and correct.
Signature of School Official
Name of School
Title of School Official
Street Address of School
Mail completed form to: California Student Aid Commission, Cal Grant Operations, P.O. Box 419077, Rancho Cordova, CA 95741-9077