*DEMO* 1617
*TRACKING REQUIREMENT*
2016-2017 SUPPLEMENTAL INFORMATION & CERTIFICATION FORM
Last Name: _____________________ First Name: __________________ MI: ___
ID#: W____________________
Do you have a Permanent Social Security Number?  Yes
 No (If yes, complete the Student Update Form)
Previously Used Name: _____________________________
 Male
 Female
DA
Tax Payer ID Number: ________________+
Street: __________________________________________City: ________________________State/Zip: _____________________
Home Phone: (_____) _____________ Other Phone: (____) __________ Personal Email: __________________________________
Verify address & phone in Class Web, and update changes with Admissions and Records; we cannot change for you. The Financial Aid Office sends e-mail notifications
to all Chabot financial aid applicants via their ZoneMail account. We recommend you forward your ZoneMail to your personal email account to ensure you receive all
communication in a timely manner; instructions are available on the Zone.
1. Has Admissions & Records classified your residency as an AB540 student for tuition purposes?  Yes  No
(attended at least three years and graduated from CA high school, have completed affidavit saying you have filed or will file for legal
immigration status) If not, and you believe you qualify, inquire with Admissions & Records.
2. Do you have a CA high school diploma or its equivalent? (i.e. GED, High School Proficiency)
 Yes  No
Year ________* High School __________________________________________________
NOTE: If no to above, and are enrolling in program of study after 7/1/12, you are ineligible for State financial aid. If you enrolled prior to 7/1/12,
you may be eligible by passing an Ability to Benefit (ATB) test or successfully completing at least six units of academic coursework.
**A student must be admitted to Chabot College (not LPC), and must be enrolled in an eligible Chabot Certificate, Associate or Transfer degree/major to
qualify for State financial aid. Each semester as you register for classes, you must ensure that you correctly identify your primary major and educational goal (i.e.
Certificate, Associate or Transfer program) with Admissions & Records. There will be no financial aid disbursements for ineligible or undeclared majors/programs.
Do you (or will you) have a Bachelor’s degree from any college or university in the U.S. or from another country by the time you would receive
financial aid from Chabot?
 Yes  No
After which term do you expect to graduate/transfer from Chabot College?
Fall / Spring / Summer 20_____
Will you be enrolled at another institution between July 1, 2016 and June 30, 2017?
 Yes  No
If yes, name of school? _________________________ Which term(s)? _______________________
Have you received (or will you receive) Federal/State funds from another school for the 2016-2017 year?
 Yes  No
If yes, from which school? _________________________ Which term(s)? __________________
1)
2)
3)
(You may only receive Financial Aid from one institution each term.)
Financial Aid regulations require that at minimum Chabot include units earned at other colleges or universities that apply toward your current program of
study at Chabot when calculating your financial aid eligibility. Specifically, we must determine if you meet minimum Satisfactory Academic Progress standard
of ability to successfully complete your program of study within the allowed time limit (measured in attempted units). You must submit official transcripts to
the Chabot Admissions & Records Office for transcript evaluation of units that may apply to a Chabot program of study. Failure to disclose prior
college/university attendance may result in you having to repay aid already received while at Chabot.
All Chabot students must have a modified SEP (Student Educational Plan) by the time they have 30 attempted units at Chabot-LPC to be considered for
financial aid. Students are required to make an appointment with an Academic Counselor to complete a modified SEP well before the start of the semester
as Counselor schedules fill up quickly. If you have prior academic units to be applied to your degree objective at Chabot, you must have official transcripts
on file with Chabot Admissions & Records Office so Counselors can include in your SEP. New students should attend a New Student Orientation through
Counseling. (See class schedule for dates and times.)
No financial aid disbursement will occur until SEP and required prior academic transcript requirements are met.
I certify that 1) I have read this entire form, understand the information it contains and agree to comply with all instructions, and 2) the information I
have provided here is true, complete and accurate to the best of my knowledge. I authorize Chabot College to deduct any outstanding fees or other charges
owed by me to Chabot-Las Positas College District from any financial aid I am entitled to receive, including charges from prior academic years. I am aware that this
authorization is voluntary and I may rescind it in writing. Any outstanding debts made prior to rescinding my authorization are subject to withholding.
Warning: If you purposely give false or misleading information on this application, you may be fined up to $20,000, sentenced to jail, or both. You will be
required to repay any and all aid that you receive as a result of false information provided, and will be referred for violation of student code of conduct for
possible disciplinary action.
Student Signature ___________________________________
Date ___________
NOTE: If you completed your Dream Act Application after March 2, you may not need to complete the verification paperwork.
It will not affect your BOG Fee Waver.
3/17/16