Financial Aid Office ● 197 Franklin St. • Auburn, NY  13021

   315-255-1743 ext. 2470 • Fax 315-252-2185





Student’s Printed Name                                                                                                    Cayuga ID #


You indicated on your FAFSA that you or your parents (if dependent student) received Food Stamps in 2012 or 2013.  Please indicate below if this information is correct and provide the required documentation by completing the following form.  Once you have entered the necessary information, you will need to print the form and provide all required signatures and return it to the CCC Financial Aid Office with supporting documentation, if necessary.

  I received Food Stamps in 2012 or 2013

Please attach a copy of your current Common Benefit identification Card (CIBC)


  I did not received Food Stamps in 2012 or 2013

Please contact the Financial Aid Office regarding corrections to your FAFSA




I certify that the above information is true and complete.  I understand that failure to accurately report

Information may jeopardize my eligibility for Financial Aid.  I also understand that the U.S. Secretary of

Education has the authority to verify information reported on the FAFSA with the Internal Revenue Service and other federal agencies.  I understand that giving false or misleading information may lead to fines up to $20,000, prison, or both.



Student Signature:________________________________________________ Date:_______________



Dependent Students Only


Parent Printed Name:_______________________________________________________________________________


Parent Signature:_________________________________________________ Date:_______________



Return this form to the Financial Aid Office at Cayuga Community College

along with a copy of your Common Benefit Card, if necessary.