Student Aid Report

STUDENT AID REPORT
2010 - 2011
WWW.FAFSA.GOV

1-800-4-FED-AID (TTY: 1-800-730-8913)

APRIL 22, 2010
000001C001

OMB No. 1845-0008

DATA RELEASE NUMBER (DRN): 9755
EXPECTED FAMILY CONTRIBUTION (EFC): 00000*C

20
09

JOHN SMITH
742 EVERGREEN TERRACE
SPRINGFIELD OH 55555

20
,

Dear JOHN SMITH,
Your Student Aid Report (SAR) summarizes the information you submitted on your 2010 - 2011 Free
Application for Federal Student Aid (FAFSA).

E:
N

O

VE

M

BE
R

Application Status (review the checked boxes)
) Your FAFSA appears to be complete. Review the data on pages 3-10 of your SAR and make corrections or updates
if necessary. The school(s) listed on your FAFSA will receive your information.
) Your FAFSA has been selected for verification. Verification is a process where your school confirms the data you
reported on your FAFSA. Your school has the authority to contact you for documentation that supports income and
other information that you reported on your FAFSA.

AT

Federal Student Aid Eligibility (review the checked boxes)

AF

T

D

The data submitted on your FAFSA is used to calculate your Expected Family Contribution (EFC), which is 00000.
The EFC is not the amount of money that your family must provide. Rather, you should think of the EFC as an index that
colleges use to determine how much financial aid you would receive if you were to attend their school. Financial aid
may include grants (free funds that do not have to be repaid), low-interest loans (borrowed funds that must be repaid),
and/or work-study (paid part-time employment). Please note that your EFC is subject to change if you update or correct
your FAFSA.

D

R

Your financial aid package could also include other federal, state, or institutional grants and scholarships, and/or a
work-study award. Your school’s financial aid office will advise you of the specific types and amounts of student aid you
are eligible to receive. For more information about the EFC, grants, loans or work-study, scholarships and other sources
of aid go to www.FederalStudentAid.ed.gov/aidInfo.
) Based on your EFC it appears that you may be eligible for a Federal Pell Grant of up to $5350, in addition to other
grants, low-interest student loans, and work-study opportunities.
) You may also be eligible for the Academic Competitiveness Grant (ACG).
) We sent your information to other federal agencies to verify your eligibility for federal student aid and there appears to
be an issue with the information provided on your application. Review the checklist on page 3 for instructions on
how to resolve these issues.
You should keep this SAR for your records!
R5EN000001 999

PAGE 1 OF 10

2010-2011 STUDENT AID REPORT
The Office of Management and Budget (OMB) wants you to know that:

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of
information unless it displays a valid OMB control number. The valid OMB control number for this information
collection is 1845-0008. The time required to complete this information collection is estimated to be an average of
10 to 34 minutes, including the time to review instructions, search existing data resources, gather the data needed,
and complete and review the information collected. If you have any comments concerning the accuracy of the
time estimate(s) or suggestions for improving this form, please write to: U.S. Department of Education, Washington,
DC 20202-4651. If you have any comments or concerns regarding the status of your individual submission of this
form, write directly to: Federal Student Aid Information Center, P.O. Box 84, Washington, DC 20044.
By answering questions 102a through 102h, and signing the Free Application for Federal Student Aid (FAFSA), you
give permission to the U.S. Department of Education to provide information from your application to the college(s)
listed in Step Six. You also agree that such information is deemed to incorporate by reference the certification
statement in Step Seven of the financial aid application. To learn more about the Privacy Act and how your
information may be used, you may refer to page 10 of the paper FAFSA or the Privacy Act link on FAFSA on the Web.
To protect the confidentiality of your application data, you should never give, share or disclose your Federal Student
Aid PIN with anyone, including commercial service providers that provide assistance with the financial aid process.
You should keep your PIN in a safe location. If you think your PIN has been compromised, please go to the Federal
Student Aid PIN web site at www.pin.ed.gov and change your PIN.
WARNING: If you are convicted of drug distribution or possession, for an offense that occurred while you were

receiving Title IV aid, your eligibility for Title IV student financial aid is subject to suspension or termination. If your
drug conviction status changes at any time during the 2010-2011 award year, you must update your answer to
question 23.

Only For Use by Financial Aid Office (skip to next page to begin your review of the data included in your SAR)
This information will be used by your Financial Aid Administrator to determine your eligibility for student aid.
Y
SAR C Flag:
4A
Application Source:
4A
Transaction Source:
Processed Record Type:
Duplicate SSN Flag:

Dependency Status: D
Dependency Override: Y
Professional Judgment: Y
Reprocessing Code:
Special Circumstances: 1

MONTHS:
1
PRIMARY EFC: 00000
SECONDARY EFC: 00000
PC:
SIC:
Auto Zero EFC Flag:
MATCH FLAGS:
SSN Match Flag:
DHS Match Flag:
DHS Sec. Conf. Flag:
NSLDS Match Flag:

Y

SNT Flag:

4

Selective Service Registration Flag: Y
DHS Verification #: 999999999999999
VA Match Flag:
1
NSLDS Results Flag:
01
NSLDS Transaction Number:

ABCDEFG
01/01/2010
01/01/2010
Y

2
3
4
5
6
7
8
9
10
11
12
00000 00000 00000 00000 00000 00000 00000 00000 00000 00000 00000
00000 00000 00000 00000 00000 00000 00000 00000 00000 00000 00000

2

Y

COMMENTS:
R5EN000001 999

Rejects Met:
Application Receipt Date:
Transaction Receipt Date:
Verification Flag:

PAGE 2 OF 10

Pell Eligible Flag:

Y

Selective Service Match:
C
SSA Citizenship Code:
4
FSSN Match Flag:
4
MSSN Match Flag:

2010-2011 STUDENT AID REPORT
COMMENTS ABOUT YOUR INFORMATION
WHAT YOU MUST DO NOW! (Use the checklist below to make sure that all of your issues are resolved.)
The National Student Loan Data System (NSLDS) indicates that one or more of your federal student loans have been
discharged. If you have questions, contact the financial aid office at your school.
If you need to make corrections to your information, you may either make them online at www.fafsa.gov, or by using this
SAR. You must use your Federal Student Aid PIN to access your record online. If you need additional help with your SAR,
contact your school's financial aid office or the Federal Student Aid Information Center at 1-800-4-FED-AID (1-800-433-3243).
If your mailing address or e-mail address changes, you can make the correction online, send in the correction on your
SAR, or call 1-800-4-FED-AID and ask a customer service representative to make the change for you.

R5EN000001 999

PAGE 3 OF 10

2010-2011 STUDENT AID REPORT
Summary of Federal Student Loans (review the loan totals listed below)

The information below is the total amount of Title IV student loans that you owe as currently reported to us by your
loan holder(s). These loan programs are administered by the U.S. Department of Education (ED). You should confirm
that these loan totals are correct. You can use your Federal Student Aid PIN to view details on the individual loans
that make up these totals at the National Student Loan Data System (NSLDS) web site at www.nslds.ed.gov. For more
information about your Federal Student Aid PIN, go to www.pin.ed.gov. If you feel that the amounts listed on this
page are incorrect, or you have other questions related to a loan, you should contact the loan servicer indicated on
the NSLDS web site. You can obtain general information about each of the types of loans that are listed below by
visiting our www.studentaid.ed.gov web site.
Note that the 'Subsidized' and 'Unsubsidized' amounts include the appropriate portions of any Consolidation
Loans you may have. If there is an amount listed for 'FFEL Unallocated Consolidation Loans' it is because we
could not determine whether those balances were subsidized or unsubsidized.
Remember you are responsible for repaying all of the amounts that you borrow, plus interest. As a general rule,
with an assumed interest rate of 5%, the monthly payment amount over a ten-year repayment period would be
approximately $10.61 for every $1,000 that you borrowed. Of course your actual repayment amount will depend
upon how much you borrow, the interest rate when you enter repayment, and the length of your repayment term.
Total Amount of Loans Outstanding:
FFEL (Bank Loans) and/or Direct Loans:
Subsidized Loans:
Unsubsidized Loans:
Combined Loans:
Unallocated Consolidated Loans:
Federal Perkins Loans:
Total Outstanding Principal Balance:
2010-2011 Award Year Loan Amount:
Teach Grants Converted to Direct Loans:
Unsubsidized Loans:

R5EN000001 999

Total Principal
Balance:
$ 6,000
$ 3,000
$ N/A
$ N/A

Remaining Amount to be
Disbursed:
$ 1,200
$ 1,300
$ N/A

Total:
$ 7,200
$ 4,300
$ N/A
$ N/A

$ N/A
$ 550
$ 1,612

PAGE 4 OF 10

$ 1,612

2010 - 2011 STUDENT AID REPORT

OMB No.

Check Your SAR

1845-0008

If you find a mistake, put the correct answer in the boxes or completely fill in an oval
(example:
).
Look for arrows (
or
) in the area next to your information. For these items, give us
a new answer, or if your current answer is correct, rewrite the same information exactly.
If you want to delete an answer, draw a line through your answer and through the empty
box or oval (example: 10. Permanent Phone Number
).
(301) 555 - 1234

Use your Federal Student Aid PIN to make corrections online at www.fafsa.gov or send in pages 5-10 of this form.

Processed: 04/20/2010

Step One: You (The Student)

1. Last Name
SMITH

2. First Name
JOHN

DRN: 9755

3. Middle Initial
J

4. Permanent Street Address
742 EVERGREEN TERRACE
5. City
SPRINGFILED
8. Social Security Number
XXX-XX-4444

6. State Abbreviation

10. Permanent Phone Number
Use MM/DD/YYYY
format (e.g., 03/01/1980) (555) 235-1885

9. Date of Birth
/

7. ZIP Code

/ 1 9

11. Driver's License Number
12. Driver's License State Abbreviation
We will use this e-mail address to correspond with you. You will receive your SAR information through a secure link on the Internet. We will only share
this address with the colleges you list on the form and your state. Leave blank to receive information through regular mail.
13. Student's E-mail Address
[email protected]
@
14. Citizenship Status
ELIGIBLE NONCITIZEN
15. Alien Registration Number
16. Marital Status (As of the date you
submitted your FAFSA)
MARRIED/REMARRIED
17. Date of Marital Status

U.S. Citizen

Eligible Noncitizen

Neither

A
Single

Married/Remarried

Separated

Remember to
completely fill in
the oval
Divorced or Widowed

21. Are you male or female?
/
Male
Female
MALE
18. State of Legal Residence Abbreviation Use MM/YYYY format (e.g., 03/1980) 22. If you are male (age 18-25) and
not registered, answer "Register Me"
IL
and Selective Service will register you. Register Me
19. Did you become a legal resident of
REGISTER ME
this state before January 1, 2005?
Yes
No
YES
20. If you answered "No" to question 19,
date you became a legal resident
/
R5EN000001 999

PAGE 5 OF 10

You Told Us

You Told Us

23. Drug Conviction Affecting Eligibility? No.............................................
ELIGIBLE FOR AID
Yes (Part-Year)........................
Yes/Don't Know......................
Middle school/Jr. High..........
24. Father's Educational Level
High school.............................
College or beyond................
HIGH SCHOOL
Other/unknown......................
25. Mother's Educational Level
Middle school/Jr. High..........
High school.............................
College or beyond................
COLLEGE OR BEYOND
Other/unknown......................
26. High School Completion Status?
High school diploma..............
GED certificate.........................
Homeschooled........................
HIGH SCHOOL DIPLOMA
None of the above..................
27. First Bachelor's Degree by 7-1-2010? Yes
No
YES
28. Grade Level in College in 2010-2011 1st/Never Attended..................
1st/Previously Attended...........
2nd/Sophomore......................
3RD/JUNIOR
3rd/Junior.................................
4th/Senior.................................
5th/Other Undergraduate.....
1st Yr. Graduate/
Professional..............................
Cont. Graduate/
Professional..............................

29. Type of Degree/Certificate

1st Bachelor's degree............
2nd Bachelor's degree.........
Associate degree
(occupational or technical
program)................................
Associate degree (general
education or transfer)..........
Certificate or diploma for
completing less than 2 years
Certificate or diploma for
completing at least 2 years
Teaching credential
(nondegree program)..........
Graduate or professional
degree.....................................
Other/undecided..................

30. Enrollment Status in 2010-2011
THREE-QUARTER-TIME
31. What Student Aid Types Interest
You?
BOTH WORK-STUDY AND
STUDENT LOANS

Full-time.................................
Three-quarter-time..............
Half-time................................
Less than half-time...............
Don't know............................
Work-study.............................
Student loans........................
Both work-study and
student loans........................
Neither...................................
Don't know............................

32. Planning to complete
coursework to be an elementary or Yes.....................................
secondary school teacher?
No......................................
Don't know.......................
YES

Step Two: 2009 Student (and Spouse) Income and Assets

For 36-45, report your (the student's) income and assets. If you are single, separated, divorced or widowed, answer only about yourself.
If you are married as of today, include information about your spouse (husband or wife). Remember to completely fill in the oval as follows:
For 36-45, if the answer is zero or the question does not apply to you,
33. Filed 2009 Income Tax Return?
Have already completed.......
enter 0. Report dollar amounts (such as $12,356.00) like this:
Will file, have not yet
completed.................................
EXAMPLE
1 2 , 3 5 6
HAVE ALREADY COMPLETED
Not going to file........................
36. Adjusted Gross Income from IRS
Form (1040-line 37; 1040A-line 21; or
34. Type of 2009 Tax Form Used
A. IRS 1040..................................
1040EZ-line 4.)
$
,
B. IRS 1040A or 1040EZ..............
$
355,000
C. A foreign tax return.............
37. U.S. Income Tax Paid from IRS Form
D. A tax return with Puerto
IRS 1040A OR 1040EZ
(1040-line 55; 1040A-line 35; or
Rico, a U.S. Territory or Freely
$
1040EZ-line 11.)
Associated State.......................
,
35. If you filed or will file a 1040, were
$
13,012
you eligible to file a 1040A or 1040EZ? Yes..............................................
38. Exemptions Claimed from IRS Form
(1040-line 6d; 1040A-line 6d; for Form
No...............................................
1040EZ see page 2 of the FAFSA.)
Don't know................................
YES
03
$

R5EN000001 999

PAGE 6 OF 10

For 39-40, answer the questions whether or not you filed a tax return. This information may be on your W-2 forms, or
on IRS Form 1040-lines 7+12+18+ Box 14 of IRS Schedule K-1(Form 1065); 1040A-line 7; or 1040EZ-line 1.
39. Student's Income Earned from Work
$
$ 250,000
,
40. Spouse's Income Earned from Work
$
$ 100,000
,
45. Student's Untaxed Income
41. Cash, Savings, and Checking (As of
the date you submitted your FAFSA)
$
,
$
a) Tax-deferred pension/savings
42. Net Worth of Investments (As of the
$
date you submitted your FAFSA)
$
,
$
b) IRA deductions and payments
43. Net Worth of Businesses/Investment
$
Farms (As of the date you submitted
$
your FAFSA)
,
c) Child support received
$
$
d) Tax exempt interest income
44. Student's Additional Financial
Information
$
e)
Untaxed
IRA distributions
a) Education credits
$
,
$ 12,000
$
f) Untaxed portions of pensions
b) Child support paid
$
,
$
$
g) Military or clergy allowances
c) Taxable earnings from
need-based employment
$
,
$
$
h) Veterans non education
d) Student grant and scholarship
benefits
$
aid reported
,
$
$ 20,000
e) Special combat pay/combat
i) Other untaxed income
pay
$
,
$ 10,000
$ 4,000
f) Earnings from work under a
j) Money received or paid on
cooperative education program
your behalf
$
,
$
$
Step Three: Student Status

$

$

$

$

$

$

$

$

$

$

,

,

,

,

,

,

,

,

,

,

Answer questions 46 - 58 in this step to determine if you will need to provide parental information. Fill in the oval to enter a new response
or correct a response.
53. Were your parents deceased, were
46. Born Before 1-1-1987?
you in foster care or a court
No
Yes
YES
No
Yes
dependent/ward?
47. Are you married (As of the date you
submitted your FAFSA)?
No
Yes
54. Are/Were an emancipated minor?
YES
No
Yes
NO
48. Working on a master's or doctorate
program in 2010-2011?
55. Are/Were in legal guardianship?
No
Yes
No
Yes
YES
NO
49. Are you on active duty in U.S. Armed
56. Have you been verified as a
Forces?
No
Yes
homeless youth?
No
Yes
NO
50. Are you a veteran of U.S. Armed
57. Has the Department of Housing and
Forces?
No
Yes
Urban Development determined you to
No
Yes
be homeless?
51. Have children who receive more
NO
than half of their support from you?
No
Yes
58. Have you been verified as an
NO
unaccompanied youth who is at risk
No
Yes
52. Have dependents other than children
for homelessness?
or spouse?
No
YES
Yes
YES
R5EN000001 999

PAGE 7 OF 10

Step Four (Parental Information): Complete this step if you (the student) answered "No" to all questions in Step Three.
Answer all the questions in Step Four about your parents even if you do not live with them. Grandparents, foster parents, legal guardians, aunts and
uncles are not considered parents on this form unless they have legally adopted you. If your parents are living and married to each other, answer the
questions about them. If your parent is single, widowed, divorced, separated or remarried, see the Notes on page 9 of the FAFSA for information.
59. Parents' Marital Status (As of the date Married/Remarried
60. Date of Marital Status
Divorced/Separated
you submitted your FAFSA)
/
Single........................
Widowed....................
WIDOWED
63. First
64. Father's/Stepfather's
61. Your Father's/Stepfather's
62. Your Father's/Stepfather's Last Name
Initial
Date of Birth
Social Security Number
XXX-XX-0123
SMITH
APRIL 23, 1964
/

65. Your Mother's/Stepmother's
Social Security Number
XXX-XX-0143

66. Your Mother's/Stepmother's Last Name
SMITH

67. First
Initial

/

68. Mother's/Stepmother's
Date of Birth
MAY 12, 1966
/

/

Provide an e-mail address
so that we can correspond
with your parents.

69. Parents' E-mail Address
[email protected]
@
70. Parents' state of legal residence
IL
71. Parent legal resident of the state
before January 1, 2005?
YES
72. If "No" to question 71, enter the date
parent became legal resident

Yes

No
/

82. If your parents' filed or will file a 1040, Yes......................................
were they eligible to file a 1040A or
No.......................................
1040EZ?
Don't know........................
83. Are either of your parents a
Yes......................................
dislocated worker (As of the date you
No.......................................
submitted your FAFSA)?
Don't know........................
DON'T KNOW

Use MM/YYYY format
(e.g., 03/1980)
For 84-93, if the answer is zero or the question does not apply, enter 0.
Report dollar amounts without cents. For 87-88, this information may be
on W-2 forms, or on IRS Form 1040-lines 7+12+18+ Box 14 of IRS Schedule
74. Parents' number of family members
K-1(Form 1065); 1040A-line 7; or 1040EZ-line 1.
in college in 2010-2011
84. Adjusted Gross Income from IRS Form
75. Parent received Supplemental
$
$ 10,000
Security Income?
,
Yes
No
YES
85. U.S. Income Tax Paid
76. Parent received food stamps?
$
$
,
Yes
No
YES
86. Exemptions Claimed
77. Parent received free/reduced price
03
lunch?
Yes
No
YES
87. Father's/Stepfather's Income
Earned from Work
78. Parent received Temporary
$
,
$
Assistance for Needy Families (TANF)?
Yes
No
88.
Mother's/Stepmother's
Income
YES
Earned from Work
$
79. Parent received Nutrition Program for
,
$
Women, Infants and Children (WIC)?
Yes
No
89. Cash, Savings, and Checking (As of
the date you submitted your FAFSA)
$
,
80. Filed 2009 Income Tax Return?
$
Have already completed
90. Net Worth of Investments (As of the
Will file, have not
NOT GOING TO FILE
date you submitted your FAFSA)
yet completed..................
$
,
$
155,000
Not going to file................
91. Net Worth of Businesses/Investment
81. Type of 2009 Tax Form Used
Farms (As of the date you submitted
A. IRS 1040..........................
$
your FAFSA)
,
B. IRS 1040A or
$
1040EZ.................................
C. A foreign tax return.....
A FOREIGN TAX RETURN
D. A tax return with Puerto
Rico, a U.S. Territory or
Freely Associated State...
73. Parents' number of family members
in 2010-2011

R5EN000001 999

PAGE 8 OF 10

DRN:1421

92. Parents' Additional Financial
Information
a) Education credits
$ 12,445
b) Child support paid
$
c) Taxable earnings from
need-based employment
$
d) Student grant and scholarship
aid reported
$
e) Special combat pay/combat
pay
$ 19,778
f) Earnings from work under a
cooperative education program
$ 401

$

,

$

,

$

,

$

,

$

,

$

,

c) Child support received
$
d) Tax exempt interest income
$
e) Untaxed IRA distributions
$ 2,000
f) Untaxed portions of pensions
$
g) Military or clergy allowances
$ 3,000
h) Veterans non education
benefits
$
i) Other untaxed income
$

93. Parents' Untaxed Income
a) Tax-deferred pension/savings
$
b) IRA deductions and payments
$ 5,000

$

,

$

,

$

,

$

,

$

,

$

,

$

,

$

,

$

,

Step Five: Student's Household Information
94. Number of Family Members in 2010-2011
5
95. Number in College in 2010-2011
1
96. Student received Supplemental Security
Income?
NO
97. Student received food stamps?
NO
98. Student received free/reduced price
lunch?
NO

Yes

No

Yes

No

Yes

No

Step Six: Student's School Information

99. Student received Temporary Assistance
for Needy Families (TANF)?
NO
100. Student received Nutrition Program for
Women, Infants and Children (WIC)?
NO
101. Are you or your spouse a dislocated
worker (As of the date you submitted your
FAFSA)?
NO

Housing Plans: 1 --

on campus

2 --

w/Parents

Yes

No

Yes

No

Yes..................
No...................
Don't know....

3 --

off campus

102.a First College Name, City and State
SALISBURY UNIVERSITY, SALISBURY MD
102.c Second College Name, City and State
UNIVERSITY OF MARYLAND, COLLEGE PARK MD
102.e Third College Name, City and State

102.f Housing Plans

102.g Fourth College Name, City and State

102.h Housing Plans

102.b Housing Plans
OFF CAMPUS
102.d Housing Plans
OFF CAMPUS

Your FAFSA information was sent to all the colleges you listed although they are not all shown here. To see all of the colleges you listed go to
www.fafsa.gov and select “View and Print Your Student Aid Report".
For more information about the colleges you listed on your FAFSA, visit College Navigator at www.nces.ed.gov/collegenavigator or view your
Student Aid Report online at www.fafsa.gov for the graduation, retention, and transfer rates.
R5EN000001 999

PAGE 9 OF 10

Step Seven: Certification, Signatures and Date
103. Date Completed
JANUARY 6, 2010
104. Signed By?
STUDENT
105. Preparer's Social Security Number
REPORTED
106. Preparer's EIN
REPORTED
107. Preparer's Signature
SIGNED

DO NOT CORRECT
DO NOT CORRECT
If you or your family paid a fee for someone
to fill out this form or to advise you on how to
fill it out, that person must complete this part.

Application Receipt Date: 1/4/2010

Please read, sign and date. You must read and sign this Certification.

If you are the student, by signing this application you certify that you (1) will use federal and/or state student financial aid only to pay the cost of
attending an institution of higher education, (2) are not in default on a federal student loan or have made satisfactory arrangements to repay it,
(3) do not owe money back on a federal student grant or have made satisfactory arrangements to repay it, (4) will notify your college if you default
on a federal student loan and (5) will not receive a Federal Pell Grant from more than one college for the same period of time.
If you are the parent or the student, by signing this application you agree, if asked, to provide information that will verify the accuracy of your
completed form. This information may include U.S. or state income tax forms that you filed or are required to file. Also, you certify that you understand
that the Secretary of Education has the authority to verify information reported on this application with the Internal Revenue Service and other
federal agencies. If you sign any document related to the federal student aid programs electronically using a Personal Identification Number (PIN),
you certify that you are the person identified by the PIN and have not disclosed that PIN to anyone else. If you purposely give false or misleading
information, you may be fined up to $20,000, sent to prison, or both.
Student Signature (Required to process your application. Sign in box below.)
1
Student
Date
SEND PAGES 5-10 OF THIS FORM TO:

Federal Student Aid Programs
P.O. Box 4694
Mt. Vernon, IL 62864-0064
OR
You may also make corrections from
the Federal Student Aid's web
site (www.fafsa.gov). You must use
your PIN to access your record online.

R5EN000001 999

JOHN SMITH

Parent Signature (one parent whose information is provided in Step Four)
2
Parent
Date

Data Entry Use Only
P

PAGE 10 OF 10Q

*

L

E

Step Seven: Certification, Signatures and Date
103. Date Completed
JANUARY 6, 2010
104. Signed By?
STUDENT
105. Preparer's Social Security Number
REPORTED
106. Preparer's EIN
REPORTED
107. Preparer's Signature
SIGNED

DO NOT CORRECT
DO NOT CORRECT
If you or your family paid a fee for someone
to fill out this form or to advise you on how to
fill it out, that person must complete this part.

Application Receipt Date: 1/4/2010

Please read, sign and date. You must read and sign this Certification.

All of the information on this SAR is true and complete to the best of my knowledge. If I am asked, I agree to give proof that my information is correct.
The proof might include a copy of the 2009 U.S. Income Tax Form filed by me or my family. If I sign any document related to the federal student aid
programs electronically using a Federal Student Aid PIN, I certify that I am the person identified by the PIN and have not disclosed that PIN to anyone
else. I understand that if I purposely give false or misleading information on this SAR, I may be subject up to a $20,000 fine, a prison sentence, or both.
If you made no changes:
Do NOT send your SAR to the address given on this page.
Follow the instructions on your SAR. You may need to
contact your school.
If you made changes:
You may make corrections from Federal Student Aid's web site Student Signature (Required to process your application. Sign in box below.)
1
Student
Date
(www.fafsa.gov).You must use your PIN to access
your record.

OR

Read the certification statement above and sign to the right.
SEND PAGES 5-10 OF THIS FORM TO:

Federal Student Aid Programs
P.O. Box 4694
Mt. Vernon, IL 62864-0064

JOHN SMITH

Parent Signature (one parent whose information is provided in Step Four)
2
Parent
Date

Data Entry Use Only
P

If you need another copy of your SAR:
Call the Federal Student Aid Information Center
at 1-800-4-FED-AID (1-800-433-3243)

R5EN000001 999

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