RETURN TO:

Office of Financial Aid & Scholarships

Cal Poly Pomona
3801 W. Temple Ave.
Pomona, CA 91768-4008
(909) 869-3700 Phone
(909) 869-4757 FAX
Name of Financial Aid Applicant (please print)

Last First Middle

Bronco Number:


2014 2015
HOUSEHOLD SIZE/STATUS VERIFICATION FORM

Your application was selected for verification. Complete the chart below and return the completed and signed form to our office.
Please keep in mind that incomplete forms and missing requested documents will create delays in processing your financial
aid award.

DETERMINE who is considered a family member. Was your parents signature required on the FAFSA?


Section A: Tell Us About Your Family Size



Parent Signature was required on FAFSA (Dependent)

No Parent Signature was required on FAFSA (Independent)


Include the following in the chart:

Yourself
The parent(s) you live with (include step-parent) OR if not
living at home, the parent(s) whose information was used
on the FAFSA.
Your parents other children ONLY IF:
The parent listed will provide at least half of their
support from July 1, 2014 to June 30, 2015, OR
The children would be required to provide parent
information completing the FAFSA.
Other people currently living with your parent(s) for whom
your parent(s) currently provide and will continue to
provide at least 51% of their support from July 1, 2014 to
June 30, 2015.

Include the following in the chart:

Yourself
Your spouse if you are married
Your children ONLY IF you will provide at least 51% of
their support from July 1, 2014 to June 30, 2015.
Other people currently living with you for whom you
currently provide and will continue to provide at least 51%
of their support from July 1, 2014 to June 30, 2015.


DO NOT LIST CHILDREN FOR WHOM YOU PAY CHILD SUPPORT.

Full Name Age Born before
January 1, 1991
(Yes or No)
Relationship to Student Name of College
STUDENT SELF CAL POLY POMONA

Continued on Page 2


Name of Financial Aid Applicant (please print)

Last First Middle

Bronco Number:



Section B: Student Information


Where will you be living while attending Cal Poly Pomona (check one):

residence hall with parents off-campus/village suites

Indicate if you are a (check one):

first time freshmen transfer continuing

Indicate if your educational status (check one):

undergraduate teaching credential masters doctoral

2
nd
BA/BS Degree 2
nd
MA/MS Degree


Section C: Sign this form


By signing this, I certify that all the information reported to qualify for student financial aid is true, complete and accurate.
I give permission to the Office of Financial Aid & Scholarships to obtain secondary verification if necessary.

Signature (Student) Date
Parent/Step-Parent Signature (If signature was required on FAFSA) Date





























Visit us online at www.csupomona.edu/~financial-aid Page 2