Personal Information First Name Last Name Date CIN/Campus Identification Number Phone Number Email Eligibility 1. Do you identify as an undocumented person? Yes No 2. Are you currently enrolled and matriculated in a degree or credential program at Cal State LA? Yes No If you answered “NO” to either of the questions above, you do not qualify for this emergency funding. If you have any questions, please contact the Glazer Family Dreamers Resource Center at [email protected]. Financial Need & Financial Aid 3. Please indicate the amount of emergency funding that you are requesting. 4. Do you qualify to submit the California Dream Act Application for Financial Aid (CDA)? Yes No If NO, please explain why you do not qualify to submit the California Dream Act Application for Financial Aid. 5. If you qualify to submit the CDA, did you submit an application for the current academic year? Yes No N/A If you qualified to submit the application but did not do so, please explain why not. 6. Are you currently receiving financial aid? Yes No 7. If you are receiving financial aid, were you offered the Dream Loan? Yes No N/A 8. If you were offered the Dream Loan, did you accept it? Yes No N/A If you were offered the Dream Loan but did not accept it, please explain why not. Unforeseen Emergency 9. Please describe in detail your current emergency financial situation, including the unforeseen emergency circumstance beyond your control and how this has negatively affected your ability to complete your academic program. 10. Please describe how you have attempted, or will attempt, to improve your situation. 11. If provided with emergency funds, please describe in detail how you plan to use the funds provided to you. Please provide a specific breakdown. Application Certification Information Authorization Yes, I give my permission No, I do not give my permission. By checking "Yes," I give permission to the Cal State LA Financial Aid and Scholarships office to release my information to the authorized individual of individuals reviewing this application from the Dreamers Resource Center. This disclosure is valid only for financial aid information. I also understand and acknowledge that other areas of the University may be consulted which may be used to determine my level of eligibility for this resource. If you do not give this permission, your application cannot be processed. Signature/Name Date All of the information on this form is true and complete to the best of my knowledge. CAPTCHA