» Fall 2021 HEERF Grant Application

Name*

Full Legal Name

Student ID #*

Phone*

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please indicate how you were how you were impacted by COVID 19.*

Educational Change/Disruption
Housing/Food Needs
Childcare
Technology Needs
Healthcare/Medical
Loss of Employment

Please describe how you were impacted by COVID 19*

I authorize Montgomery Community College to apply my grant award towards any outstanding balances I may have. Any remaining funds will be refunded by paper check.*

Yes
No

By agreeing, you declare that you meet all qualifying criteria, and all information on this form is complete and correct to the best your knowledge, and that you have been impacted by COVID-19. If you are asked, you agree to give proof that all information is correct. You understand that if you purposely give false or misleading information, you may be subject to a $20,000 fine, a prison sentence, or both. If you are approved, you will be contacted via your MCC Student e-mail with the award amount and further instructions.*

I Agree
I Disagree

Signature*