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Student Affidavit

This form is to be filled out by every current and new CCC student applying for or receiving Financial Aid.

Fields marked with an asterisk (*) are required.
Personal Information
Last Name:
First Name:
Middle Initial:
Social Security Number:
Email Address:

Release of Information
I hereby authorize Clearwater Christian College and any of its designated officials to release information from my official college records to donors of scholarships, State of Florida, U.S. Department of Education, lenders of federal loans or their representatives in relation to eligibility for, or any financial assistance received.

Statement of Education Purpose & Refund/Default Certification
I certify that I do not owe a refund on any grant, am not in default on any loan, and have not borrowed in excess of the loan limits under the Title IV programs at any institution. I will use any money I receive under the Title IV or a State of Florida financial aid program only for expenses related to my studies at Clearwater Christian College.

Application of Funds & Refunds Authorization
I authorize Clearwater Christian College to apply any federal Title IV funds received to all charges incurred by myself at the institution for educationally related activities. I also authorize Clearwater Christian College to retain any excess of federal Title IV funds in my account until I formally request a refund in writing or until the end of the award year for which I received these funds occurs. If excess federal loan funds remain on my student account at the end of the award year, Clearwater Christian College will return these funds to the appropriate lender.

The above authorizations will remain in effect until I am no longer enrolled at Clearwater Christian College or until such a time as a cancel or modify this authorization.

Statement of Registration Status
Check all that apply:

I certify that I am registered with Selective Service.
I certify that I am not required to be registered with Selective Service, because:
I am female.
I am in the armed services on active duty. (Note: Does not apply to members of the Reserves and National Guard who are not on active duty.)
I have not reached my 18th birthday.
Birth Date:
I was born before 1960.
I am a foreign student here on a lawful non-immigrant visa; I am a citizen of the Federated State of Micronesia or the Marshall Islands and have not lived in the U.S. for more than one year except as a student; I am a citizen of American Somoa with a permanent address outside of the U.S.

WARNING: If you purposely give false information on this form, you may be subject to fine, imprisonment, or both. (20 U.S.C. 1091 and 50 U.S.C App. 462) (s.837.06,F.S.)

I certify that the information I have provided is correct and accurate.
I agree