Free Student Financial Aid Report, HCF 16021 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16021 (07/08)

SCHL

STUDENT FINANCIAL AID REPORT
Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants Medicaid benefits but does not provide an SSN or apply for one will not be able to get benefits. SSNs and personally identifiable information will be used only for the direct administration of the Medicaid program. AGENCY USE ONLY Case Name Worker Name Address ­ Street/P.O.Box Case Number Worker Telephone City State County/Tribal Agency Zip Code

Student Name Address ­ Street School

Student Telephone Number City State

Social Security Number Zip Code

Numbers 1 Through 7, To Be Completed by Student Financial Aid Officer. Yes No 1. Has the student applied for financial aid? Yes No 2. Has the award letter been signed and returned to the school? If the answer is "no", to questions 1 or 2, please sign and date here and return to the county/tribal agency listed above. Signature 3. 4. 5. 6. Date Signed No To
Date Amount $ $ $ $ $ $ Date

Is the student enrolled at least half-time? Yes No Yes Does the curriculum normally require a high school diploma or equivalent? What are the beginning and end dates of the current semester/trimester? From List gross amount of assistance, by semester/trimester and date of availability.
Amount $ $ $ $ $ $ Date Amount $ $ $ $ $ $ Date Type Amount

Type NDSL WSL/ GSL PELL WHEG. WTG SEOG

JTPA* VET* DVR* CWSP
OTHER OTHER

$ $ $ $
$ $

7. Budget items covered by student aid. Tuition Mandatory Fees a. Origination & loan fees b. Curriculum specific costs $ $ $ Books Miscellaneous Personal Expenses Transportation $ $ $ Other $ $ $

SIGNATURE - Financial Aid Officer

Date Signed

STUDENT AUTHORIZATION TO SHARE INFORMATION - I authorize the exchange of information between the county/tribal agency listed above, and the Student Financial Aid Office of the listed school. Information regarding the kinds and amounts of aid which I am receiving or I am eligible to receive through each program may be exchanged. I will be provided with a copy of any and all information exchanged between either agency upon my request. Date Signed SIGNATURE - Student

*County, contact the financial aid agency for the dollar amount. Distribution: County/Tribal Agency-Original Student Financial Aid Office-Copy

RESET FORM
Student-Copy