College of Pharmacy Application for Health Professions Loans (Title VII)

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1 This page is required of ALL PharmD students applying for need-based Health Professions loans. Parental Information should be entered online using the FAFSA If parent(s) filed a 2013 US income tax form, they should submit (or update) their income information on the FAFSA using the IRS Data Retrieval Tool. Parents who are unable to access the FAFSA online must print and complete the following two pages to be submitted with THIS page. My parent will use the IRS Data Retrieval tool to supply financial aid data: ( ) Yes ( ) No If your parents are deceased, or your sole custodial parent is deceased, please indicate: ( ) Death Certificate attached, or ( ) Death Certificate previously submitted. Priority Deadline: October 20, Final Deadline: November 20. Funds Are Limited. Print Name: Student ID# ( ) I want to be considered for Federal Health Professions loans which require parental information. ( ) If offered I will review the promissory note carefully before e-signing and accepting the funds. Requirements for consideration: Submit this Application to the Office of Scholarships and Financial Aid, University of Arizona. Faxed or ed submissions are acceptable. See contact information below. File the Free Application for Federal Student Aid (FAFSA) and list the University of Arizona o Although College of Pharmacy students are independent according to Step Three on the FAFSA, these Health Professions Programs under the Department of Health and Human Services require parental information, regardless of age, tax or marital status. Did you attend Medstart at the University of Arizona? ( ) No ( ) Yes What year? Have you participated in an academic enrichment program funded in whole or in part by the Health Careers Opportunity Program (HCOP) or by the Nursing Workforce Diversity (NWD) Program, formerly the Nursing Educational Opportunities Program (NEOP)? ( ) No ( ) Yes ( ) HCOP ( ) NWD ( ) NEOP What year? Where? Did you attend the Minority Medical Education Program (MMEP) in 2001 or later? ( ) No ( ) Yes What year? I certify that all information listed above is true and complete to the best of my knowledge. Student Signature: Date: September 28, 2014 D Golden-Davis Return to: F: P a g e

2 Note that processing time will be significantly shorter by entering this information directly on the FAFSA. 2 P a g e

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4 Do not leave blanks to indicate 0 in numerical fields. You must enter zero (0). 4 P a g e

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6 Certification and Signatures: If you are the parent or the student, by signing this application you certify that all of the information you provided is true and complete to the best of your knowledge and you agree, if asked, to provide information that will verify the accuracy of your completed form. This information may include U.S. or state income tax forms that you filed or are required to file. Also, you certify that you understand that the Secretary of Education has the authority to verify information reported on this application with the Internal Revenue Service and other federal agencies. If you sign any document related to the federal student aid programs electronically using a personal identification number (PIN), you certify that you are the person identified by the PIN and have not disclosed that PIN to anyone else. If you purposely give false or misleading information, you may be fined up to $20,000, sent to prison, or both. Student Printed Name Student Signature Date Mother s Printed Name Mother s Signature Date Father s Printed Name Father s Signature Date 6 P a g e