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South Carolina LIFE Scholarship Required Certification and Affidavit

2011-2012 Read, complete and sign this affidavit and return it to the address below. If you wish, you may fax the form to the number below. The completed and signed form must be returned to the Financial Aid Office. If this signed document is not returned, it will be assumed that you cannot or do not wish to sign and the LIFE Scholarship award will be rescinded. As a South Carolina LIFE Scholarship recipient, I certify that I have never been convicted of any felonies. I Further, I certify that I have not been convicted of a second or subsequent alcohol or other drug-related misdemeanor offense(s) during the preceding calendar year (defined as 12 months from the date of the start of school for the period of this award). If I am adjudicated delinquent or am convicted or plead guilty or nolo contendere to any felonies or any alcohol or drug related misdemeanor offenses under the laws of this or any other state, I agree to notify the Financial Aid Office by the start of school. I hereby give permission for a background check to be conducted to verify the above. I understand additional information may be requested after the background check has been conducted. In addition, for that purpose of determining my LIFE Scholarship eligibility, I certify that I have submitted all previous and current official transcript(s) for all eligible institutions that I have ever attended to USCB for use in determining a LIFE Scholarship grade point average (GPA). I also affirm that if I take courses during or after signing this document, I will submit any additional transcript(s) to USCB. I understand that all academic work from all eligible institutions will be used to determine a LIFE GPA only and that the LIFE GPA will not be used for USCB academic standing or for graduation purposes. To be eligible for the LIFE Scholarship Enhancement for the 2011-12 year, I understand that I must be enrolled in a declared major in an eligible math or science program at the end of the Fall 2011 drop/add period. If the LIFE Scholarship Enhancement funds are disbursed to me and I change my major to an ineligible program before the end of the Fall 2011 drop/add period, I understand that I must repay the enhanced amount of the scholarship. I understand that any false information provided or any attempt to expend any scholarship funds for unlawful purposes or any purpose other than in payment or reimbursement for the cost of attendance at the University of South Carolina Beaufort will be cause for immediate cancellation. I understand that a student who has obtained a scholarship through means of a willfully false statement or failure to reveal any material fact, condition, or circumstances affecting eligibility will be subject to applicable civil or criminal penalties, including retroactive loss of the scholarship. I also affirm that I am not currently in default on any Federal or State student loans nor do I owe any refunds to any Federal or State financial aid programs. Note: A response must be provided to one of the following statements: I certify that: (check one) I do not have an Associate or Bachelor Degree, Certificate or Diploma from a college or university. I received an Associate or Bachelor Degree, Certificate or Diploma from the below college or university: in Name of Institution

Month/Year Received

Print Full Name: _________________________________________ SSN: (Last 4 numbers only) ___________________ Signature: _____________________________________________ Date: _____________________

Any changes in eligibility criteria will be posted on our website as well as on the website of the SC Commission on Higher Education at LIFE Scholarship certification requirements are based on current SC law. Any or all of these requirements are subject to change by the SC General Assembly without notice.


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