College Student Verification Form

If there is a member of the household who is or will be enrolled in a college or a university please have them fill out and return this form with the rest of the required recertification documents.

Date

College or University attending:

Enrollment date:

Number of credits completed (not including current credits):

Number of credits currently enrolled in:

Number of credits needed to graduate:

Anticipated graduation date:

Number of credits completed during last calendar year:

Anticipated number of credited to be completed in the next calendar year:

Have you registered for the next semester's classes?

Yes

How many credits have you registered or will you be registering for:

Sign Here

First Name

Last Name

Choose how to sign

Draw Type

I agree to electronically sign and to create a legally binding contract between the other party and myself, or the entity I am authorized to represent.