SANTA MONICA COLLEGE

2017-2018 Board of Governors Fee Waiver Signature Page

(BOG B - Dependent)

Aug 20, 2017

Based on the information that you provided Santa Monica College, you appear to be
eligible for a 2017-2018 BOG Enrollment Fee Waiver. Waivers are awarded for the
current term in which the application is submitted and for following terms in the
Financial Aid Year. Waivers are not awarded retroactively to prior terms.
In order to complete the BOG application process, you and your parent must read the
"certification" and sign below. Make sure that the BOG IINFORMATION SUMMARY is
correct.

Please return the signed signature page in person, by fax or scan and email to SMC
Financial Aid Office within "seven days". The Financial Aid Office fax number is:
310-434-3650. The email address is: financialaid@smc.edu. Be sure to include BOG in
the subject line of the email.

CERTIFICATION FOR ALL APPLICANTS: READ THIS STATEMENT AND SIGN BELOW
I hereby swear or affirm, under penalty of perjury, that all information on this form is true
and complete to the best of my knowledge. If asked by an authorized official, I agree to
provide proof of this information, which may include a copy of my and my spouse/registered
domestic partner and/or my parent's/registered domestic partner's 2016 U.S. Income Tax
Return(s). I also realize that any false statement or failure to give proof when asked may
be cause for the denial, reduction, withdrawal, and/or repayment of my waiver. I authorize
release of information regarding this application between the college, the college district,
and the Chancellor's Office of the California Community Colleges.

Applicant's Signature______________________________________ Date_____________________

Parent's Siganture__________________________________________Date_____________________

After submitting this signature page, you can view your Financial Aid Status and
those semesters that you are eligible for the BOG Fee Waiver on Corsair Connect -
Financial Aid.

BOG Information Summary

Name: QUINTANA KEVIN ID: 1634196 DOB: 13-NOV-96 Married:N
Addr: 1502 6TH AVE
Phone: 323-202-5835
LOS ANGELES, CA 90019
Household Size: 3 Parent's Income: 18268