2016-17 Enrollment History Verification Form

2016-17 Enrollment History Verification Form
Last Name
First Name
MI
Social Security Number
Student ID
Date of Birth
Verification of Enrollment History
1. Did you attend and receive Pell Grant and/or Federal Direct Loans at Moreno Valley College, Norco
College or Riverside City College at any time during the 2012-2013, 2013-2014, 2014-2015 or
2015-2016 academic years?
 Yes: Please stop here and sign the bottom of this form. No additional action required.
 No: Please see #2 below. You may be required to submit additional documentation.
2. Did you attend and receive Pell Grant and/or Federal Direct Loans at any other college or University
during the 2012-2013, 2013-2014, 2014-2015 or 2015-2016 academic years?
 Yes: The US Department of Education requires that you submit unofficial transcripts from every
college or university you attended during the 2012-2013, 2013-2014, 2014-2015 and 2015-2016
academic years. Please answer question #3 below.
 No: Please stop here and sign the bottom of this form. No additional action required.
3. Did you earn academic credit at any college or University you attended during the 2012-2013, 20132014, 2014-2015 or 2015-2016 academic years for which you received Pell Grant and/or Federal Direct
Loans? Academic credit is considered to have been earned if you completed any credit hours or clock
hours.
 Yes: Please sign the bottom of this form and submit all unofficial transcripts as requested in question
#2.
 No: The US Department of Education requires that you submit the following:
•
•
A signed statement explaining why you failed to earn academic credit at the
colleges/universities you attended during the 2012-2013, 2013-2014, 2014-2015 and 2015-2016
academic years for which you received Pell Grant and/or Federal Direct Loans.
Documentation supporting your explanation why you failed to earn academic credit at the
2012-2013, 2013-2014, 2014-2015 and 2015-2016 academic years.
Your documents will be reviewed to determine eligibility for financial assistance and you will be notified by
email to your MVC, NC or RCC student email account. If you are missing any requested documents or it is
discovered that you attended a college/university for which you did not submit transcripts, determination of
eligibility will be delayed.
By signing this worksheet, I certify that all the information reported on it is complete and correct.
Student Signature
Date
Warning: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
All applications for financial assistance programs (i.e., student loans, work compensation, grants, scholarship, special funds, subsidies, prizes, etc.), will be considered by the Riverside Community College District without regard to ethnic group identification, national origin,
religion, age, gender, gender identity, gender expression, race, color, ancestry, genetic information, sexual orientation, physical or mental disability, or any characteristic listed or defined in Section 11135 of the Government Code or any characteristic that is contained in the
prohibition of hate crimes set forth in subdivision (1) of Section 422.6 of the California Penal Code, or any other status protected by law. Alternate formats for this material are available to individuals requiring disability accommodation. Please contact the office of Diversity,
Equity and Compliance at (951) 222-8039.
Todas las solicitudes para programas de asistencia financiera (por ejemplo, préstamos estudiantiles, compensación de trabajo, subvenciones, becas, fondos especiales, subvenciones, premios, etc.), serán considerados por el Distrito de Riverside Community College
independientemente de identificación étnica, origen nacional, religión, edad, género, identidad de género, expresión de género, raza, color, ascendencia, información genética, orientación sexual, discapacidad física o mental, o cualquier característica listados o definidos en la
Sección 11135 del Código de Gobierno o cualquier característica que se encuentra en la prohibición de los crímenes de odio establecidos en la subdivisión (1) de la Sección 422.6 del Código Penal de California, o cualquier otra condición protegida por la ley. Formatos
alternos para este material están disponibles para personas que requieran alojamiento de discapacidad. Por favor comuniquese con la oficina de Diversidad, Equidad y Respeto al (951) 222-8039.