Grant Record Chang Grant Record Change Form For Students Or Students Cal Grant Program
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Grant Record Chang
Grant Record Change F
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orm For Students
or Students
or Students
or Students
Award Year
Grant Record Chang
Grant Record Chang
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or Students
Cal Grant Program
Cal Grant Program
Cal Grant Program
Cal Grant Program
Cal Grant Program
(e.g) 2004 / 2005)
Please read instructions on the reverse side before completing. Print or type all information.
Please read instructions on the reverse side before completing. Print or type all information.
Please read instructions on the reverse side before completing. Print or type all information.
Please read instructions on the reverse side before completing. Print or type all information.
Please read instructions on the reverse side before completing. Print or type all information.
Complete this form to notify the California Student Aid Commission (Commission) of any changes in your name,
social security number, address, school, or to request a leave of absence.
SECTION 1. STUDENT INFORMATION
SECTION 1. STUDENT INFORMATION
SECTION 1. STUDENT INFORMATION
SECTION 1. STUDENT INFORMATION
SECTION 1. STUDENT INFORMATION
1. Student’s name (Current last, first, middle initial)
Last Name
First Name
MI
If this is a name change, please print PREVIOUS name in shaded box
PREVIOUS name in shaded box
PREVIOUS name in shaded box and attach a copy of the driver's license, SSN card or marriage certificate.
PREVIOUS name in shaded box
PREVIOUS name in shaded box
Last Name
First Name
MI
2. Social security number - If submitting a correction, please print the INCORRECT NUMBER in the shaded box
INCORRECT NUMBER in the shaded box
INCORRECT NUMBER in the shaded box
INCORRECT NUMBER in the shaded box
INCORRECT NUMBER in the shaded box and attach a copy of the correct SSN
card.
3. Date of birth
4. Telephone number - where you can be reached during the day
(
)
/
/
5. Address: Is this an address change?
Yes
No
Street address
City
State
Zip code
SECTION 2. SCHOOL CHANGE
SECTION 2. SCHOOL CHANGE
SECTION 2. SCHOOL CHANGE
SECTION 2. SCHOOL CHANGE
SECTION 2. SCHOOL CHANGE
6. Change of school: I wish to change my school of attendance. Indicate the date for which you are requesting a school change (e.g. August 2005).
School name
City
Date
7a. School change effective
Fall term
Winter term
Spring term
Summer term
(check one):
7b. I plan to reside (check one):
On campus (dorm)
Off campus (apartment, etc.)
At home with parents or relatives
SECTION 3. LEAVE OF ABSENCE REQUEST
SECTION 3. LEAVE OF ABSENCE REQUEST
SECTION 3. LEAVE OF ABSENCE REQUEST
SECTION 3. LEAVE OF ABSENCE REQUEST
SECTION 3. LEAVE OF ABSENCE REQUEST
A leave of absence or series of leaves which total more than the equivalent of one academic year,
may not be approved. The Commission may grant extended leaves in exceptional circumstances. You may refer to your Cal Grant Reference manual for more
information on the leave of absence policy. Please attach supporting documents (such as a doctor's note) to request any leave in excess of one academic year.
8. School of attendance or most recent attendance
Date and term last attended
I request a Leave of Absence for the following term(s): Check box(es)
Fall term
Winter term
Spring term
Indicate exact dates for which you are requesting a Leave of Absence: From:
To:
9. Briefly state your reason(s) for a leave of absence: (please print or type — attach additional pages or documentation if necessary)
SECTION 4. STUDENT’S SIGNATURE
SECTION 4. STUDENT’S SIGNATURE
SECTION 4. STUDENT’S SIGNATURE
SECTION 4. STUDENT’S SIGNATURE
SECTION 4. STUDENT’S SIGNATURE (
)
YOU MUST SIGN AND DATE THIS FORM
10. Signature (I certify to the best of my knowledge that this information is true and correct.)
Date
G-10 (2/05)
(OVER)
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