State of Texas Funding Certification Form

First Name

Middle Name

Last Name

Student ID Number

Email Address

Birthdate

Mailing Address

Country

Street

City

Region

Postal Code

Are you currently registered for Selective Service?

I was born female and not required to register

I was born male and am under the age of 18 and not currently required to register

I was born male and am REGISTERED with the Selective Service.

I was born Male and am over the age of 18. I am not registered with Selective Service and I am not exempt from registration with Selective Service

I was born male and am EXEMPT from registration.

Briefly explain why you are exempt.

Are you required to pay child support but are more than 30 days delinquent on payments?

Yes

No

Per Texas Family Code, Title 5, Section 231.006, a student who is obligated to pay child support and is more than 30 days delinquent is not eligible to receive a state-funded grant or loan.

I hereby certify that the information I have provided in this statement is true and correct. I understand that if I fail to provide accurate information, I may be required to reimburse the institution and penalties may be imposed. I also understand that it is my responsibility to inform the financial aid office if my status concerning this statement of eligibility changes at any time while attending this institution.

Student Signature