2018-2019
Proof of Dependent / Child
Office of Student Financial Aid
1021 Dulaney Valley Road
Baltimore, Maryland 21204-2794
P: 410-337-6141
F: [See Web Page for current #]
E: finaid@goucher.edu
________________________________ _____________________ _____________________
Student Last Name Student First Name Goucher ID Number
You have indicated on the FAFSA that you have a child or dependent. In order to claim this on the 2018-2019 FAFSA, you
must provide more than 50% of his or her financial support through June 30, 2019. Total support includes, but is not
limited to, the money you spend to provide food, housing, clothing, personal items, medical/dental care, education,
childcare, long term care, transportation, and similar necessities.
Dependent’s/Child’s Name: _____________________________ Relationship to You: _________________________
Please answer the following questions concerning the support of your dependent/child.
1. Where do you (or will you) live while in school? ☐By myself ☐With parents
☐With other: ____________________________________________________ (name & relationship)
Source of income for rent/mortgage (check all that apply): ☐Myself ☐Parent
☐Other: _____________________________________ (name & relationship) ☐Subsidized Housing
2. Where does the dependent/child live while you are in school?
☐With me ☐With someone else: _____________________________________ (name & relationship)
3. Who pays (or will pay) for childcare? (if applicable) ___________________________________________________
4. Who pays (or will pay) for food? __________________________________________________________________
5. Who pays (or will pay) for medical needs? __________________________________________________________
6. Do you (or will you) receive any of the following federal benefits?
WIC ☐Yes ☐No TANF ☐ Yes ☐ No
Food Stamps (SNAP) ☐Yes ☐ No Other: _____________ ☐ Yes ☐ No
By signing this worksheet, I certify that all information on this sheet is true and accurately describes my situation from
now through June 30, 2019. Not completely filling out this form may result in a delay in your file being processed.
_____________________________________________ _____________________________
Student Signature Date
(ELECTRONIC SIGNATURES NOT ACCEPTED. Please print & sign in ink, then mail, fax, or scan and e-mail.)
