SANTA MONICA COLLEGE

2016-2017 Board of Governors Fee Waiver Signature Page

(BOG B - Independent)

May 18, 2016

Based on the information that you provided Santa Monica College, you appear to be
eligible for a 2016-2017 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 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 2015 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_____________________

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: LY LUCKY ID: 1529334 DOB: 22-MAY-94 Married:N
Addr: 10941 Strathmore Dr Apt 64
Phone: 612-272-1250
Los Angeles, CA 90024
Household Size: 1 Applicant's Income: 14639