Paper Student Aid Report

2014-2015 Federal Student Aid Application

SAR_ENGLISH_09262013

Federal Student Aid Application

OMB: 1845-0001

⚠️ Notice: This form may be outdated. More recent filings and information on OMB 1845-0001 can be found here:

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STUDENT AID REPORT
2014-2015
WWW.FAFSA.GOV

OMB No. 1845-0001

APRIL 22, 2014
000001C001

F 211 1415

DATA RELEASE NUMBER (DRN): 9755
EXPECTED FAMILY CONTRIBUTION (EFC): 000000*C

JOHN SMITH
742 EVERGREEN TERRACE
SPRINGFIELD OH 55555

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Dear JOHN SMITH,
Your Student Aid Report (SAR) summarizes the information you submitted on your 2014-2015 Free Application for
Federal Student Aid (FAFSA).
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.

Federal Student Aid Eligibility (review the checked boxes)

The data submitted on your FAFSA is used to calculate your Expected Family Contribution (EFC), which is 000000.
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.

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, work-study, scholarships and other sources of
aid, go to StudentAid.gov.
) Based on your EFC it appears that you may be eligible for a Federal Pell Grant of up to $5785, provided you have not
met or exceeded the lifetime limit established for the Federal Pell Grant program. You may also be eligible for other
grants, low-interest student loans, and work-study opportunities.
) 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

2014-2015 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 such collection displays a valid OMB control number, which for this form is 1845-0001. Public
reporting burden for this collection of information is estimated to average 10 to 34 minutes per response, including
time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and
completing and reviewing the collection of information. The obligation to respond to this collection is voluntary.
Send comments regarding the burden estimate or any other aspect of this collection of information, including
suggestions for reducing this burden, to the Federal Student Aid Information Center, P.O. Box 84, Washington, D.C.
20044.

By answering questions 103a through 103h, and signing the 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.

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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 2014-2015 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:
Y
High School Flag:
1
2
MONTHS:
000000 000000
PRIMARY EFC:
SECONDARY EFC: 000000 000000
PC:
SIC:
Y
Auto Zero EFC Flag:
MATCH FLAGS:
4
SSN Match Flag:
DHS Match Flag:
DHS Sec. Conf. Flag:
NSLDS Match Flag: 2
NSLDS Unusual Enrollment
1
History Flag:
COMMENTS: 001 115 006
R5EN000001 999

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

ABCDEFG
Rejects Met:
Application Receipt Date: 01/01/2014
Transaction Receipt Date: 01/01/2014
Y
Verification Flag:
IRS Request Flag: Student: 01 Parent: 01
IRS Display Flag: Student: A Parent: C
3
4
5
6
7
8
9
10
11
12
000000 000000 000000 000000 000000 000000 000000 000000 000000 000000
000000 000000 000000 000000 000000 000000 000000 000000 000000 000000
Simplified Needs Test Flag:

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

PAGE 2 OF 10

Pell Eligible Flag:

Selective Service Match:
C
SSA Citizenship Code:
4
P1SSN Match Flag:
4
P2SSN Match Flag:

2014-2015 STUDENT AID REPORT
COMMENTS ABOUT YOUR INFORMATION

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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 visit www.fafsa.gov and click the "Help" icon on the FAFSA home page. If your
mailing address or e-mail address changes, you can make the correction online or send in the correction on your SAR.

R5EN000001 999

PAGE 3 OF 10

2014-2015 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 StudentAid.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 Federal Family Education Loan (FFEL) Program 'Unallocated
Consolidation Loans,' it is because we could not determine whether those balances were subsidized or unsubsidized.

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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 10-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:

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

$ 1,612

T
AF
R
D
R5EN000001 999

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

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

$ N/A
$ 550

FFEL (Bank Loans) and/or Direct Loans:
Subsidized Loans:
Unsubsidized Loans:
Combined Loans:
Unallocated Consolidated Loans:
Federal Perkins Loans:
Total Outstanding Principal Balance:
2014-2015 Award Year Loan Amount:
Teach Grants Converted to Direct Loans:
Unsubsidized Loans:

PAGE 4 OF 10

$ 1,612

2014-2015 STUDENT AID REPORT

OMB No.

Check Your SAR

1845-0001

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: 01/01/2014

Step One: You (The Student)

1. Last Name
SMITH

2. First Name
JOHN

DRN: 9755

3. Middle Initial
J

5. City
SPRINGFIELD

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4. Mailing Address
742 EVERGREEN TERRACE
6. State Abbreviation

8. Social Security Number
XXX-XX-4444

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

9. Date of Birth
/

11. Driver's License Number
12. Driver's License State Abbreviation

7. ZIP Code

We will use your e-mail address to communicate with you electronically. We will also share your e-mail address with your state and the colleges
listed on your FAFSA to allow them to communicate with you. If you do not have an e-mail address, leave this field blank.
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 Change

@
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, 2009?
Yes
No
YES
20. If you answered "No" to question 19,
date you became a legal resident
/
Use MM/YYYY format (e.g., 03/2011)
PAGE 5 OF 10
R5EN000001 999

You Told Us

29. Grade Level in College in
2014-2015

30. Type of Degree/Certificate

1ST BA

28. First Bachelor's Degree by 7-1-2014?
YES

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27.c High School State
MD

Yes

31. Are you interested in being
considered for work-study?

1st Bachelor's degree............
2nd Bachelor's degree.........
Associate degree
(occupational or technical
program)................................
Associate degree (general
education or transfer)..........

3RD/JUNIOR

27.a High School Name
PRINCE GEORGE'S COUNTY HIGH SCHOOL

27.b High School City
BELTSVILLE

1st/Never Attended..................
1st/Previously Attended...........
2nd/Sophomore......................
3rd/Junior.................................
4th/Senior.................................
5th/Other Undergraduate.....
1st Yr. Graduate/
Professional..............................
Cont. Graduate/
Professional..............................

23. Drug Conviction Affecting Eligibility? No.............................................
ELIGIBLE FOR AID
Yes (Part-Year)........................
Yes/Don't know......................
Middle school/Jr. High..........
24. Parent 1 Educational Level
High school.............................
College or beyond................
HIGH SCHOOL
Other/unknown......................
Middle school/Jr. High..........
25. Parent 2 Educational Level
High school.............................
College or beyond................
COLLEGE OR BEYOND
Other/unknown......................
26. High School Completion Status?
High school diploma..............
GED or equivalent...................
Homeschooled........................
HIGH SCHOOL DIPLOMA
None of the above..................

Step Two: 2013 Student (and Spouse) Income and Assets

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

YES
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 or remarried, as of today, include information about your spouse (husband or wife). Remember to completely fill in the oval as follows:
35. If you filed or will file a 1040, were
32. Filed 2013 Income Tax Return?
Already completed.................
you eligible to file a 1040A or 1040EZ? Yes....................................
Will file........................................
No.....................................
ALREADY COMPLETED
Will not file.................................
Don't know.......................
YES
33. Type of 2013 Tax Form Used
1040............................................
For 36-45, if the answer is zero or the question does not apply to you,
enter 0. Report dollar amounts (such as $12,356.00) like this:
1040A/EZ....................................
EXAMPLE
Foreign tax return.....................
, 1 2,3 5 6
1040
36. Adjusted Gross Income from IRS
U.S. Trust territory.......................
Form (1040-line 37; 1040A-line 21; or
1040EZ-line 4.)
34. Tax Return Filing Status 2013
$ ,
Single........................................
,
$ 1,355,000
Head of household................
37. U.S. Income Tax Paid from IRS Form
Married-filed joint return........
(1040-line 55; 1040A-line 35; or
MARRIED-FILED SEPARATE RETURN
Married-filed separate return
1040EZ-line 10.)
$ ,
,
Qualifying widow(er).............
$ 1,113,012
Don't know...............................
38. Exemptions Claimed from IRS Form
(1040-line 6d; 1040A-line 6d; for Form
1040EZ see page 2 of the FAFSA.)
03
$

R5EN000001 999

PAGE 6 OF 10

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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 (Code A) of IRS Schedule K-1 (Form 1065); 1040A-line 7; or 1040EZ-line 1.
39. Student's Income Earned from Work
$
,
,
$ 1,250,000
40. Spouse's Income Earned from Work
$
$ 1,100,000
,
,
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 noneducation
d) Taxable student grant and
benefits
scholarship aid reported to IRS
$
,
,
$
$ 20,000
e) Combat pay/special combat
i) Other untaxed income
pay
$
,
,
$
$ 4,000
f) Earnings from work under a
j) Money received or paid on
cooperative education program
your behalf
$
,
,
$
$
Step Three: Student Dependency 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 1-1-1991?
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 2014-2015?
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 questions in Step Four even if you do not live with your legal parents (your biological and/or adoptive parents). 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 married to each
other, or are not married to each other and live together, answer the questions about both of them. See the Notes on page 9 of the FAFSA for information.
60. Date of Marital Status
59. Parents' Marital Status (As of the date
Married/Remarried
Never married...............
you submitted your FAFSA)
Divorced/Separated
/
Unmarried and both
parents living together
Widowed...................
WIDOWED
63. First
64. Parent 1 Date of Birth
62. Parent 1 Last Name
61. Parent 1 Social Security Number
Initial
XXX-XX-0123
SMITH
APRIL 23, 1964
B
/

XXX-XX-0143

68. Parent 2 Date of Birth

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69. Parents' E-mail Address
[email protected]

67. First
Initial
J

66. Parent 2 Last Name
SMITH

MAY 12, 1966

65. Parent 2 Social Security Number

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

70. Parents' state of legal residence
IL
71. Parent legal resident of the state
before January 1, 2009?
YES
72. If "No" to question 71, enter the date
parent became legal resident

73. Parents' number of family members
in 2014-2015
74. Parents' number of family members
in college in 2014-2015

Single........................................
Married-filed joint return........
Married-filed separate return
Yes
No
MARRIED-FILED SEPARATE RETURN
Head of household................
Qualifying widow(er).............
/
Don't know...............................
Use MM/YYYY format 83. If your parents' filed or will file a 1040,
Yes......................................
(e.g., 03/2011)
were they eligible to file a 1040A or
No.......................................
1040EZ?
Don't know........................
84. Are either of your parents a
Yes......................................
dislocated worker (As of the date you
No.......................................
submitted your FAFSA)?
Yes
No
Don't know........................
DON'T KNOW
For 85-94, if the answer is zero or the question does not apply, enter 0.
Report dollar amounts without cents. For 88-89, this information may be
Yes
No
on W-2 forms, or on IRS Form 1040-lines 7+12+18+ Box 14 (Code A) of IRS
Schedule K-1 (Form 1065); 1040A-line 7; or 1040EZ-line 1.
85. Adjusted Gross Income from IRS Form
Yes
No
$ 10,000
$ ,
,
86. U.S. Income Tax Paid
Yes
No
$ ,
,
$
87. Exemptions Claimed
Yes
No
03
88. Parent 1 Income Earned from Work
Already completed..........
$ ,
,
$
Will file.................................
89. Parent 2 Income Earned from Work
Will not file..........................
$ ,
,
$
90. Cash, Savings, and Checking (As of
1040.....................................
the date you submitted your FAFSA)
1040A/EZ.............................
$ ,
,
$
Foreign tax return.............
91.
Net
Worth
of
Investments
(As
of
the
U.S. Trust territory................
date you submitted your FAFSA)
$ ,
,
$ 155,000

75. Parent received Supplemental
Security Income?
YES
76. Parent received Supplemental
Nutrition Assistance Program (SNAP)?
YES
77. Parent received free/reduced price
lunch?
YES
78. Parent received Temporary
Assistance for Needy Families (TANF)?
YES
79. Parent received Nutrition Program for
Women, Infants and Children (WIC)?

82. Tax Return Filing Status 2013

80. Filed 2013 Income Tax Return?
WILL NOT FILE
81. Type of 2013 Tax Form Used
FOREIGN TAX RETURN

R5EN000001 999

PAGE 8 OF 10

DRN:1421

94. b) IRA deductions and payments
$ 5,000
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 noneducation
benefits
$
i) Other untaxed income
$

a) Tax-deferred pension/savings
$

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a) Education credits
$ 12,445
b) Child support paid
$
c) Taxable earnings from
need-based employment
$
d) Taxable student grant and
scholarship aid reported to IRS
$
e) Combat pay/special combat
pay
$ 19,778
f) Earnings from work under a
cooperative education program
$ 401
94. Parents' Untaxed Income

92. Net Worth of Businesses/Investment
Farms (As of the date you submitted
your FAFSA)
$
$
93. Parents' Additional Financial
Information

$ ,
Step Five: Student's Household Information

Yes

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

Yes

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

95. Number of Family Members in 2014-2015
05
96. Number in College in 2014-2015
1
97. Student received Supplemental Security
Income?
NO
98. Student received Supplemental
Nutrition Assistance Program (SNAP)?
NO
99. Student received free/reduced price
lunch?
NO

Step Six: Student's School Information
103.b Housing Plans
ON CAMPUS

103.c Second College Name, City and State
UNIVERSITY OF MARYLAND
COLLEGE PARK, MD
New
New School
School
Name, City,
Code
State

103.d Housing Plans
ON CAMPUS

103.a First College Name, City and State
NEW BRUNSWICK INSTITUTE OF TECHNOLOGY
PORTLAND, OR
New
New School
School
Name, City,
Code
State

R5EN000001 999

Housing Plans:

1 --

PAGE 9 OF 10

2 -3 --

on campus
w/parents
off campus

103.f Housing Plans
OFF CAMPUS

103.g Fourth College Name, City and State
UNIVERISTY OF TEXAS
AUSTIN, TX
New
New School
School
Name, City,
Code
State

103.h Housing Plans
OFF CAMPUS

Housing Plans:
1 -- on campus
2 -- w/parents
3 -- off campus

103.e Third College Name, City and State
UNIVERISTY OF MISSOURI
ST LOUIS, MO
New
New School
School
Name, City,
Code
State

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 “Student Aid Report (SAR)".
For the graduation, retention, and transfer rates of the colleges listed on your FAFSA, view your Student Aid Report online at www.fafsa.gov. You can
find these rates and other important consumer information about the colleges you're interested in attending at www.nces.ed.gov/collegenavigator.

107. Preparer's EIN
108. Preparer's Signature
Application Receipt Date: 01/05/2014

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104. Date Completed
JANUARY 01, 2014
105. Signed By?
BOTH
106. Preparer's Social Security Number

Step Seven: Certification, Signatures and Date

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.

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 certify that all of the information you provided is true and complete to the best of
your knowledge and 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
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

103.f Housing Plans
OFF CAMPUS

103.g Fourth College Name, City and State
UNIVERISTY OF TEXAS
AUSTIN, TX
New
New School
School
Name, City,
Code
State

103.h Housing Plans
OFF CAMPUS

Housing Plans:
1 -- on campus
2 -- w/parents
3 -- off campus

103.e Third College Name, City and State
UNIVERISTY OF MISSOURI
ST LOUIS, MO
New
New School
School
Name, City,
Code
State

107. Preparer's EIN
108. Preparer's Signature
Application Receipt Date: 01/05/2014

AT
E
SA : S
M EP
PL T
E EM
D B
AT E
A R2

104. Date Completed
JANUARY 01, 2014
105. Signed By?
BOTH
106. Preparer's Social Security Number

Step Seven: Certification, Signatures and Date

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.

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 2013 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 fined up to $20,000, sent to prison, 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.)
(www.fafsa.gov). You must use your PIN to access
1
Student
Date
your record.

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
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

P
PAGE 10 OF 10V

File Type	application/pdf
File Modified	2013-09-26
File Created	2013-09-26