Financial Aid Office · 197 Franklin Street, Auburn NY 13021· FAX 315-252-2185

Auburn - 315-255-1743 ext. 2470 · Fulton 315-592-4143 ext. 3004




Student Name                                                                                                                                                




Please complete the following form.  Once you have entered the necessary information online, you

will need to print the form, provide all required signatures and return it to the CCC Financial Aid

Office.  Additional information may be requested.


The income reported on your application for federal student financial aid was very low.  Normally a student and his/her family must pay expenses for basic living costs of room and board.  If there was little or no income, please explain below how these expenses were paid.  (Attach additional pages, if needed.)  If you were required to report parents’ income on the FAFSA, please provide an explanation of how parent expenses were met.  If you were not required to report parents’ income, please explain how student expenses were met.










If these expenses during 2012 were paid by someone whose income is not required to be reported on the financial aid application, please explain the relationship and have that person sign the statement below.






 I provided room and board for the above named student during 2012.  I also provided cash assistance of

 $______________  during 2012.


 Signature ________________________________________________       Date__________________



Signature of Student________________________________________        Date__________________


Signature of Parent ________________________________________         Date__________________

(if dependent)


Processing of your application for Financial Aid cannot continue

until we receive the requested information.