Dependent Worksheet West Hills Community College District (Page 4 of 4) in pdf

Dependent Worksheet West Hills Community College District Page 4

Student’s Name: __________________________________________ SSN/WHC ID#: __________________________

F. Dependent Student’s Parents’ Receipt of SNAP Benefits Certification Statement

Did anyone in your parents’ household receive food stamp benefits from the Supplemental Nutrition

Assistance Program or SNAP (formerly known as the Food Stamp Program) anytime during 2013 or

2014? For assistance in determining the name used in a state, please call 1-800-4FED-AID (1-800-433-

3243)

Yes, and if asked I will provide documentation from the agency that issued the SNAP benefits in 2013or 2014.

NOTE: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we

may require documentation from the agency that issued the SNAP benefits in 2013 or 2014.

G. Certification and Signature

I certify that all of the information reported on this worksheet is complete and correct. I am aware that if I purposely give false or

misleading information on this worksheet, I may be fined, sentenced to jail, or both. Both student and parent must sign this worksheet.

Student Signature

Date

Parent’s Signature

Date

Dependent Worksheet West Hills Community College District Page 4