California Community Colleges 2015-16 Board Of Governors Fee Waiver Application Form (Page 2 of 2) in pdf

13. Are you (the student ONLY) currently receiving monthly cash assistance for yourself or any dependents from:

TANF/CalWORKs?



Yes



SSI/SSP (Supplemental Security Income/State Supplemental Program)?



Yes



General Assistance?



Yes



14. If you are a dependent student, are your parent(s)/RDP receiving monthly cash assistance from TANF/CalWORKs or SSI/SSP as a primary source of income?



Yes



If you answered "Yes" to question 13 or 14 you are eligible for an ENROLLMENT FEE WAIVER. Sign the Certification at the end of this form. You are required to

show current proof of benefits. Submit application and documentation to the financial aid office.

METHOD B ENROLLMENT FEE WAIVER

15. DEPENDENT STUDENT: How many persons are in your parent(s)/RDP household? (Include yourself, your parent(s)/RDP, and anyone who lives with your

parent(s)/RDP and receives more than 50% of their support from your parents/RDP, now and through June 30, 2016.) _________

16. INDEPENDENT STUDENT: How many persons are in your household? (Include yourself, your spouse/RDP, and anyone who lives with you and receives more than 50%

of their support from you, now and through June 30, 2016.) ___________

17. 2014 Income Information

(Dependent students should not include their income information f

DEPENDENT STUDENT:

INDEPENDENT STUDENT:

or Q 17 a and b below.)

PARENT(S)/ RDPINCOME ONLY

STUDENT (& SPOUSE'S/ RDP) INCOME

Adjusted Gross Income (If 2014 U.S. Income Tax Return was filed,

enter the amount from Form 1040, line 37; 1040A, line 21; 1040EZ, line 4). $

All other income (Include ALL money received in 2014 that is not

included in line (a) above (such as disability, child support, military living

allowance, Workman’s Compensation, untaxed pensions).

TOTAL Income for 2014 (Sum of a + b)

The Financial Aid Office will review your income and let you know if you qualify for an ENROLLMENT FEE WAIVER under Method B. Submit application and

documentation to the financial aid office.

If you do not qualify using Method A or Method B, you should file a FAFSA (for U.S. citizens or eligible non-citizens) or the California Dream Application (for

undocumented AB 540 students). The FAFSA is available at and the Dream Application is available at https://dream.csac.ca.gov/. Contact the

Financial Aid Office for more information.

SPECIAL CLASSIFICATIONS ENROLLMENT FEE WAIVERS

18.

Do you have certification from the CA Department of Veterans Affairs that you are eligible for a dependent's fee waiver?





Submit certification.

Yes

19.

Do you have certification from the National Guard Adjutant General that you are eligible for a dependent's fee waiver?

Submit certification.



Yes



20.

Are you eligible as a recipient of the Congressional Medal of Honor or as a child of a recipient?

Submit documentation from the Department of Veterans Affairs.



Yes



21.

Are you eligible as a dependent of a victim of the September 11, 2001, terrorist attack?



Submit documentation from the CA Victim Compensation and Government Claims Board.

Yes

22.

Are you eligible as a dependent of a deceased law enforcement/fire suppression personnel killed in the line of duty?

Submit documentation from the public agency employer of record.



Yes





If you answered "Yes" to any of the questions from 18-22, you are eligible for an ENROLLMENT FEE WAIVER and perhaps other fee waivers or adjustments. Sign

the Certification below. Submit application and documentation to the financial aid office. Contact the Financial Aid Office if you have questions.

CERTIFICATION FOR ALL APPLICANTS: READ THIS STATEMENT AND SIGN BELOW

I hereby swear or affirm, under penalty of perjury, that all information on this form is true and complete to the best of my knowledge. If asked by an authorized official, I agree to provide proof of

this information, which may include a copy of my and my spouse/registered domestic partner and/or my parent's/registered domestic partner’s 2014 U.S. Income Tax Return(s). I also

realize that any false statement or failure to give proof when asked may be cause for the denial, reduction, withdrawal, and/or repayment of my waiver. I authorize release of information regarding

this application between the college, the college district, and the Chancellor's Office of the California Community Colleges.

I understand the following information (please check each box):

 Federal and state financial aid programs are available to help with college costs (including enrollment fees, books & supplies, transportation and room and board expenses). By completing the

FAFSA or the California Dream Application, additional financial assistance may be available in the form of Cal Grants, Pell and other grants, work study and other aid.

 I may apply for and receive financial assistance if I am enrolled, either full time or part time, in an eligible program of study (certificate, associate degree or transfer).

 Financial aid program information and application assistance is available in the college financial aid office.

Applicant’s Signature

Date

Parent Signature (Dependent Students Only)

Date

ALIFORNIA

NFORMATION

RIVACY

State and federal laws protect an individual’s right to privacy regarding information pertaining to oneself. The California Information Practices Act of 1977 requires the following information be provided to financial aid applicants who are asked to supply information

about themselves. The principal purpose for requesting information on this form is to determine your eligibility for financial aid. The Chancellor’s Office policy and the policy of the community college to which you are applying for aid authorize maintenance of this

information. Failure to provide such information will delay and may even prevent your receipt of financial assistance. This form’s information may be transmitted to other state agencies and the federal government if required by law. Individuals have the right of

access to records established from information furnished on this form as it pertains to them.

The officials responsible for maintaining the information contained on this form are the financial aid administrators at the institutions to which you are applying for financial aid. The SSN may be used to verify your identity under record keeping systems established

prior to January 1, 1975. If your college requires you to provide an SSN and you have questions, you should ask the financial aid officer at your college for further information. The Chancellor’s Office and the California community colleges, in compliance with

federal and state laws, do not discriminate on the basis of race, religion, color, national origin, gender, age, disability, medical condition, sexual orientation, domestic partnership or any other legally protected basis. Inquiries regarding these policies may be

directed to the financial aid office of the college to which you are applying.

FOR OFFICE USE ONLY



RDP



BOGFW-A

BOGFW-B

Special Classification

Student is not eligible

Student



TANF/CalWORKs