(OVER)
Student Name: ____________________________________ NSCC ID number: N________________________
Street Address _________________________________ City________________ State_________ Zip____________
Phone: _________________ Email Address: ______________________________ Date of Birth: _____/_____/_____
This appeal is used to request a dependency override for federal financial aid. It is used after you have filed your FAFSA and indicated that
you have special circumstances which prevent you from providing parental information.
The Federal Student Aid Program determines a student’s status as dependent or independent by the answers the student provides on the eight
questions listed in Step 3 of the Free Application for Federal Student Aid (FAFSA). Students are classified as dependent or independent
because federal student aid programs are based on the principle that students (and their parents or spouse) are considered the primary source
of support for postsecondary education. The Dependency Override process is used to address on a case by case basis a student who claims to
be independent but does not meet the federal criteria. The student must demonstrate a unique and extenuating circumstance.
The following provides information and explains the procedure used to determine a student’s eligibility for a “Dependency Override.” A
Financial Aid Administrator will review the student’s appeal by examining the supporting documentation provided by the student and will
either approve or deny the students request and notify the student in writing. The decision is final and cannot be appealed to the U.S.
Department of Education.
THE FOLLOWING IS NOT CONSIDERED A UNIQUE AND EXTENUATING CIRCUMSTANCE
Self-sufficiency of the student
Parent’s unwillingness to complete the parent section of
the FAFSA
Parents refuse to contribute to the student’s education
Not residing at the parent’s residence
Not being claimed as a dependent on your parent’s tax
return
Student’s desire for grants instead of loans
CIRCUMSTANCES GIVEN CONSIDERATION WHERE PARENTAL SUPPORT HAS BEEN TERMINATED
Documented abandonment
Parental drug abuse
Parental mental incapacity
Physical or emotional abuse
Severe estrangement from parents
Parental Incarceration
Dependency Override Appeal Process
_____Step #1: Complete your 2019-2020 Free Application for Federal Student Aid and have it sent to NSCC (School Code 008677).
_____Step #2: Complete this form using an ink pen.
_____Step #3: Attach a typed letter. Make sure your name, Student ID, date, and signature are included on the letter.
In your own words tell us why you are requesting a dependency override.
Describe your relationship with your parents and include any circumstances surrounding the situation
Include information about how you provide for yourself.
If you are or have received support from friends and relatives, you must describe the nature of the support.
Attach supporting documentation if available.
_____Step #4: Have at least two individuals complete the “Dependency Override Documentation” section of this appeal.
These individuals should be adults who have direct knowledge of the situation, who are not relatives.
One individual must be a professional whom you have sought treatment or assistance. Professionals include guidance counselors,
doctors, lawyers, family counselors, social workers, law enforcement officers, clergy members, etc.
If a family member, who is not your parent, has raised you or is currently supporting you, submit an additional statement from that
family member.
The Dependency Override Documentation must be the original form completed and signed by each individual.
We understand the sensitive nature of these circumstances; therefore all documentation received by our office will be kept
confidential.
2019-2020 Dependency
Override Application
Prior Petition for Dependency Override Approval
____ Check here if you have been approved for a Dependency Override Appeal in 2018-2019 aid year by our office and your situation
has not changed. You do not have to resubmit the documentation you previously provided. Just complete this page of the form and
submit to the Financial Aid Office.
Parent Information: Father Mother
Name: __________________________________________ Name: __________________________________________
Address: __________________________________________ Address: __________________________________________
__________________________________________ __________________________________________
Phone: __________________________________________ Phone: __________________________________________
Student Information:
1. Did anyone claim you on their federal tax return for 2017? ____Yes ____No 2018? ____ Yes ____No
If yes for 2017, provide Name: _________________________________ Relationship to you: _______________________________
If yes for 2018, provide Name: _________________________________ Relationship to you: _______________________________
2. What are your current living arrangements (who do you live with)? ____________________________________________________
3. Current Expenses:
Type of Expenses
Monthly Amount
How Paid
Housing
$
Utilities
$
Food
$
Clothing
$
Transportation
$
Medical/Insurance
$
Personal/Miscellaneous
$
4. When was the last time you lived with your parent(s)? Month/Year:___________________________
5. When did your parent(s) last provide any form of support? Month/Year:___________________________
Student Certification:
I certify that all of the information provided on this form and all attached documentation is true and correct. I also understand that it will be used to override
federal regulations regarding my dependency status. I fully understand that to falsify any information in order to receive Federal Title IV funds is a federal
offense and can be punishable by fines and/or other penalties. I understand that if my situation changes in any way, if I reside with my parents or receive any
financial support from them, that I must report this information to the Financial Aid Office.
____________________________________________ __________________________
Student’s Signature Date
Northwest State Community College does not discriminate on the basis of race, color, national origin, sex, gender identity, disability, religion or age in its programs or
activities.
For Financial Aid Office Use Only:
Outcome: ____ Eligible for Dependency Override Corrections Entered in Banner (RNAOVxx): Date ____________
____ Not eligible for Dependency Override
Comments: ____________________________________________________________________________________________________________________
___________________________________________________________________________________________________________________
Financial Aid Authorization: ____________________________________________________________ Date:____________________________________
Student Name:
NSCC ID number:
Northwest State Community College • 22600 State Route 34 • Archbold • OH • 43502
Phone: 419-267-1333 • Fax 419-267-5587 • finaid@northweststate.edu
Dependency Override Documentation
Professional
Student Name: ___________________________________ NSCC ID number: N________________________
TO BE COMPLETED BY A PROFESSIONAL WHO HAS WORKED WITH THE STUDENT’S FAMILY.
(EXAMPLES OF PROFESSIONAL PEOPLE INCLUDE HIGH SCHOOL COUNSELOR, TEACHER, SOCIAL
WORKER, CLERGY, PHYSICIAN, LAWYER, or FAMILY THERAPIST).
The above named student has applied for financial aid at Northwest State Community College and has indicated that he/she is
unable to provide us with parent information due to extenuating family circumstances.
Please provide a brief statement regarding your knowledge of the student’s family history and relationship with parent(s).
_______________________________________________________________________________________________________
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_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Why do you believe that the student is unable to provide parent(s) information for financial aid purposes?
_______________________________________________________________________________________________________
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Last date the student: 1. Received financial support from parent(s)? ____________ 2. Lived with parent(s)?___________
How long have you known the student? _______________________________________________________________________
What is your professional relationship with the student? __________________________________________________________
Name of Business or Employer: _____________________________________________________________________________
Business Address: _____________________________________ Business Phone #:_____________________________
Your name (please print): ________________________________ Your Title: __________________________________
Your Signature: ________________________________________ Date: _______________________________________
Northwest State Community College • 22600 State Route 34 • Archbold • OH • 43502
Phone: 419-267-1333 • Fax 419-267-5587 • finaid@northweststate.edu
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Dependency Override Documentation
Non-Relative Individual
Student Name: ___________________________________ NSCC ID number: N________________________
TO BE COMPLETED BY AN INDIVIDUAL WHO IS AN ADULT AND HAS DIRECT KNOWLEDGE OF THE
STUDENT’S SITUATION, WHO IS NOT A RELATIVE. THIS PERSON MUST NOT LIVE AT THE SAME
ADDRESS AS THE STUDENT.
The above named student has applied for financial aid at Northwest State Community College and has indicated that he/she is
unable to provide us with parent information due to extenuating family circumstances.
Please provide a brief statement regarding your knowledge of the student’s family history and relationship with parent(s).
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Why do you believe that the student is unable to provide parent(s) information for financial aid purposes?
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Last date the student: 1. Received financial support from parent(s)? ____________ 2. Lived with parent(s)?___________
How long have you known the student? _______________________________________________________________________
What is your relationship with the student? __________________________________________________________
Your name (please print): ________________________________ Your Phone #: ________________________________
Your physical address: ____________________________________________________________________________________
Street Number and Street Name City State Zip
Your Signature: ________________________________________ Date: _______________________________________
Northwest State Community College • 22600 State Route 34 • Archbold • OH • 43502
Phone: 419-267-1333 • Fax 419-267-5587 • finaid@northweststate.edu