Desert Cedars - Financial Aid Application

Desert Cedars - Financial Aid Application

This is an application for students in financial need seeking coverage for mental health services.
Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Phone number (10-digit)
Email
example@stanford.edu
What type of student are you?

Other
Are you claimed as a dependent on someone else's taxes (e.g. your parents)?
Do you claim others as Dependents on your own Tax Returns?

Income: Please provide information of you and your family's current income. If Not Applicable, please write N/A

Rows	Estimated Monthly Income
Wages (Self)
Wages (Spouse)
Wages (Other Family Member)
Self-Employment
Public Assistance
Unemployment Compensation
Alimony/Child Support
Military Family Allotments
Income ( Dividends/Interest/Rent)
Other Income (Pensions/Retirement/Social Security)

Please report the following on you and your family's assets. Please put NA for any fields that do not apply.

Rows	Approximate Value
Cash (All Accounts: Savings, Checking, CDs, etc.)
Home (if owned)
Other Properties (if owned)
Automobile (if owned)
Stock / Equity (if owned)
Other

Please report the following on you and your family's expenses. Please put NA for any fields that do not apply.

Rows	Estimated Monthly Expenses
Mortgage/Rent
Utilities
Phone
Food
Finance/other loans
Auto Loans
Other

Please upload documentation supporting your claim of financial need.
- Undergraduates - Most recent financial aid award letter
- Graduate students who are not dependents - FAFSA or grad school application showing expected familiy contribution (EFC)
- Graduate students claimed as dependents - Tax Returns on which you are a depdendent (e.g. your parents')
- If required, we may also ask for verification of school enrollment, credit and bank account statements, and property ownership.
Please upload documentation supporting your claim of financial need.

Browse Files

Cancelof
I certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct. I also grant a mutual release of information, allowing Desert Cedars to communicate with Acacia Mental Health, including sharing my mental health diagnosis, recommended treatment(s), dates of treatment, the nature of treatments delivered, whether or not Desert Cedars will cover all or part of my treatment, and information about what has or has not been paid. I do NOT grant permission to share my detailed background financial information; the attached file(s) are only used by Desert Cedars to determine coverage eligibility and will NOT be shared with Acacia Mental Health. I agree to tell Desert Cedars, within 30 days, if there are any changes in my or my family's income, property, expenses, or in the persons of my household or of any changes of addresses. I understand that I may be asked to prove my statements and that my eligibility statements may be subject to verification by contact with my school, employer, bank, credit verification and/or property searches.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate