Last Name:
First Name: Student ID:
Student’s Current Address:
Based on the results of your 2016-2017 Free Application for Federal Student Aid (FAFSA), you did not report information about your parent(s). You indicated you have special circumstances.
If all of the following apply, please complete and return this form:
• You have contact (regardless of how much) with your parent(s) but you do not live with them,
• You do not receive ANY support from your parent(s); this includes any payment of educational costs, cash, and non-cash support to the student, such as room/board, payment of bills on child’s behalf (cell phone, auto insurance, auto payments), health insurance, or support of any kind, etc.
• Your parent(s) have refused to complete the parent portion of the 2016-2017 FAFSA
Parent Certification: Please list the parent(s) names:
Parent 1: Parent 2:
Parent(s) Current Address:
 I/We certify that I/we do not provide any financial support to my/our child (as listed on this form).
Date financial support ceased
 I/We refuse to complete the parent portion of the 2016-2017 FAFSA.
 I/We understand that by completing this form, I/we cannot apply for a 2016-2017 Federal Direct Parent PLUS
Loan.
I certify that the information above is true and accurate to the best of my knowledge.
Parent Signature Date
Continue to Page 2 for Student Certification and Signature
2016-2017 No Parent Information 03/11/16

STUDENT CERTIFICATION
 What is your current living arrangement?
With Parents Do you pay rent? Yes. If yes, submit proof of rental payments No
With Roommates or Relatives On Own
 To accept my Federal Direct Unsubsidized Loan I must complete Smart Borrowing for Loans . Register through myACCESS by following instructions on our website at http://www.cod.edu/financial_aid_events
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I am a Freshman (less than 30 earned credit hours) – eligible for $5,500 for the academic year.
I am a Sophomore (30 or more earned credit hours) – eligible for $6,500 for the academic year.
My parents are no longer providing support and have signed the Parent Certification.
 If your parent(s), as applicable for the FAFSA, refuse to sign and date this form or another statement to this effect, you must submit supporting documentation from a third party that is able to explain the situation. This statement should be from an adult who has direct knowledge of the current situation or a professional from whom you have sought assistance and include their contact information. Professionals include guidance counselors, doctors, lawyers, family counselors/therapists, social workers, law enforcement officers, clergy members, etc.
NOTE: Failure to submit supporting documentation will delay the processing of this status and the determination for an Unsubsidized loan.
By signing this form, I acknowledge that I will be ineligible to receive any other Title IV Financial Aid (Grants, Subsidized
Loans, Federal Work Study, etc.) if this form is approved. I further certify that all information on this form is true, complete and accurate. Upon request I agree to provide additional proof of the information reported on this form.
Warning: If you purposely give false or misleading information, you may be fined up to $20,000, sent to prison, or both.
Student Signature Date
Please return this form to:
College of DuPage, Office of Student Financial Assistance – SSC 2220
425 Fawell Blvd., Glen Ellyn, IL 60137 FAX (630) 942-2151 EMAIL: financialaid@cod.edu
The college will not discriminate in its programs and activities on the basis of race, color, religion, creed, national origin, sex, age, ancestry, marital status, sexual orientation, arrest record, military status or unfavorable military discharge, citizenship status, physical or mental handicap or disability (Board Policy 5010; 20-5).
OSFA USE ONLY □ Approved □ Denied □ Committee Review
Reject Status = X: Y N Comment Code: 295 300 SC Flag: 1 4
FAFSA Housing: 1 – On Campus 2 – With Parents
Budget:
3 – Off Campus
Loan Eligibility: Freshman Sophomore
Documentation Received:
Notes:
FA Representative Signature:
Committee Review & Decision: Yes No Reason:
Date: