NAME:
SOCIAL SECURITY #: - -
ADDRESS:
DATE OF BIRTH: / / PHONE NUMBER: -
Major:
As of this date, are you (check one)?
Unmarried (single, divorced, widowed) Married Separated
Have you ever applied for EOPS at Miramar College? Yes No
Are you a member of a household with an active TANF case number? Yes No
If yes, when did you sign your W2W plan? / /
If yes, where are you employed?
How many hours do you work per week?
Date your TANF/CalWORKs benefits began? / /
Who pays for your childcare?
Do you ride the bus or drive a car to school?
Who will you support between July 1, and June 30, of this academic year? Include:
* Yourself * Your spouse (if applicable) *Your dependent children
Full Name Age Relationship (self)
ALL APPLICANTS READ THIS STATEMENT AND SIGN BELOW:
I hereby swear of affirm, under penalty of perjury, that all information on this form is true and complete to the best of my knowledge. I also realize that any false statements or failure to give proof when asked may be cause for the denial, reduction, withdrawal, and/or repayment of my grant. I authorize release of information regarding this application between the college district, and the Chancellor's office, California Community College.
Return to EOPS Home Page Return to Miramar College Home Page
PLEASE PRINT OUT FORM AND BRING OR MAIL IT TO EOPS (C-301, Miramar College)
Miramar College 10440 Black Mountain Road San Diego, CA 9226 - 2999 (619) 388 - 7869 (858) 536 - 7869 mailto:jthompso@sdccd.net
