Financial Aid Office
1200 16th Street
Golden CO 80401
303-384-2252 fax
Receipt of SNAP Benefits

Student: ___________________________________ Campus Wide I.D.#:___________________________

The student (if independent) or parents (if the student is dependent) certify that a member of the
household, received benefits from the Supplemental Nutrition Assistance Program or SNAP (formerly
known as the Food Stamp Program) sometime during 2014 or 2015. SNAP may be known by another
name in some states. For assistance in determining the name used in a state, please call
1-800-4FED-AID (1-800-433-3243).

____ Yes, a member of our household received SNAP benefits in 2014 or 2015.

____ No, at no time during the 2014 or 2015 year did any family members receive SNAP benefits.

Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is
inaccurate, we may require documentation from the agency that issued the SNAP benefits in 2014 or

By signing below, I certify that all the information reported on this worksheet is complete and correct.
WARNING: If you purposely give false or misleading information on this worksheet, you may
be fined, be sentenced to jail, or both.

Student ____________________________________

Parent (if dependent) _____________________________________