NAME_________________________________ SS#_______________________
 (print)   Last                                 First

1) Will you live with your parents from June '05 through May '06?
                                   Yes_____                    No_____

2) Will you pay expenses such as day-care or baby-sitting for any household
     member in 2005-06?
                                    Yes_____                    No_____

3) Are you interested in :  Summer 05 Work-Study_____
               Academic year Work-Study_____       Perkins Loan_____

_________________________________________           ___________________
Student's Signature                                                                      Date
  

****************************** FOR OFFICE USE ONLY ******************************

A)  Lives with?       NLWP = Y                   Lives away?           NLAP = Y 

B)  Child/Elder care:       Yes?         NCHCR = Y            No?        NNOCHCR = Y 

C)  Verification Required?       V Code:    N    V 

D)   Federal Edits?  Attach documentation.       CUNY Edits?    Make notes. 

E)    Professional Judgement?      Attach documentation.
  
COUNSELOR'S NOTES______________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________ _________________________________________________________________

Counselor's Signature______________________          Date_____________