2003/2004 CALIFORNIA COMMUNITY COLLEGE
BOARD OF GOVERNORS ENROLLMENT FEE WAIVER

This application will only waive your registration and health fees.  If you do not qualify for this automatic fee waiver or if you need assistance with other college costs, you should complete the Free Application for Federal Student Aid (FAFSA) for additional consideration.

Print and fill out this form.  Return to the Financial Aid Office. 

Name:___________________________________________ SS#______/______/______

Address: ___________________________________________ Phone:_______________________

You must be a California resident to receive a Fee Waiver:

Has the Admissions Office determined that you are a California resident? Yes   No

DEPENDENCY STATUS

1. Were you born before January 1, 1980? Yes  No   --> Date of Birth:_____________ 

2. Are you a veteran of the U.S. Armed Forces? Yes No

3. Are you married? Yes No  -->  Single   Married   Divorced   Separated   Widowed

4. Are you an orphan or a ward of the court, or were you a ward of the court until your 18th birthday? Yes No

5. Do you have legal dependents other than a spouse that receive more than half of their support from you? Yes No

--> If you answered "Yes" to any of the questions numbered 1 to 5, you are considered an INDEPENDENT student and must provide income and household information about you (and your spouse). Skip to METHOD A below.

--> If you answered "No" to questions 1 to 5, complete the following questions.

6. Were you, or will you be claimed as an exemption by  either or both of your parents on their 2002 U.S. income tax return? Yes   No   Parent(s) won't file

7. Do you live with one or both of your parents? Yes   No

-->  If you answered "No" to questions 1 to 5 and and "Yes" to question 6 or 7, you are DEPENDENT.  Provide income and household information about your parent(s).

--> If you answered "No" or "Parent(s) won't file" to question 6 and "No" to question 7, you are INDEPENDENT.  Provide income and household information about yourself (and your spouse).

 

METHOD A

8. Are you receiving benefits from: 
   TANF/CalWORKs Yes   No    SSI/SSP   Yes  No   General Assistance Yes   No

9. If you are a dependent student, are your parent(s) receiving TANF/CalWORKs or SSI/SSP as their only source of income? Yes   No

10. Do you have certification from the California Department of Veterans Affairs or the National Guard Adjutant General that you are eligible for a dependent's fee waiver? Yes   No

11. Are you a recipient of the Congressional Medal of Honor or a child of a recipent, or a dependent of a victim of the Sept. 11, 2001 terrorist attack? Yes   No

--> If you answered "Yes" to question 8, 9, 10 or 11 you may be eligible.   sign the Certification below. Proof of benefits must be provided. 

-->If you answered "No" to question 8, 9, 10 and 11,  continue to  Method B below.

 

METHOD B

12. DEPENDENT STUDENT: How many persons are in your parent'(s) household? (Always include yourself your parent(s), and anyone who lives with your parent(s) and receives more than 50% of their support from them)

      __________________

13. INDEPENDENT STUDENT: How many persons are in your household? (Include yourself your spouse, and anyone who lives with you and receives more than 50% of their support from you.)

      __________________

CERTIFICATION --All applicants must read this statement and sign below.

I hereby swear and affirm, under penalty of perjury, that all information on this form is true and complete to the best of my knowledge. If requested, I agree to give proof of income from all sources. I realize that any false statement or failure to give proof when asked may result in the denial, withdrawal, and/or repayment of my waiver. I authorize release of information from this application between the college, the college district, and the Chancellor's Office of the California Community Colleges.  I also authorize release to the UC's and/or CSU's for the purpose of providing me with information about transfer opportunities.

Applicant's Signature___________________ Date______________

Parent's Signature_____________________ Date______________

Office Use Only

Medi-Cal Case Number____________________ Date of Birth________________ Issue Date______________ Primary Aid Code_____________________

Centified By_____________             Date___________________