RETURN THIS COMPLETED FORM WITH REQUIRED DOCUMENTATION TO:
Wayne Community College - Financial Aid Office - PO Box 8002 - Goldsboro, NC 27533-8002
FAX: 919-736-9425
Wayne Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees.
Contact the Commission on Colleges at 1866 Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation
of Wayne Community College. The Commission on Colleges may be contacted only if there is evidence that Wayne Community College is significantly
non-compliant with a requirement or standard. Accreditation standards are located at: http://www.sacscoc.org/principles.asp.
Inquiries about Wayne Community College, such as admission requirements, financial aid, educational programs, etc. should be addressed directly to
Wayne Community College and not the Commission’s office.
4) Do you provide medical coverage for the listed
dependent(s)?
(Answer YES if you are receiving Medicaid)
YES NO
If YES: attach a copy of the medical card(s)
5) Do you RECEIVE child support for the listed
dependent(s)?
YES NO
If YES: Enter the total support you received in
2017: $ _______________
Enter the total support you expect to receive in
2018: $ _______________
6) Do you PAY child support for the listed dependent(s)?
YES NO
If YES: Enter the total support you paid in 2017:
$ _______________
Enter the total support you expect to pay in
2018: $ _______________
7) Are you currently employed? YES NO
If YES: Attach a copy of your most recent pay
stub showing year to date earnings.
8) Do any of your OR the listed dependents’ relatives
provide financial support?
(for bills, personal items, diapers, etc.)
YES NO
If YES: Name of relative: _________________
Relationship to you: _____________________
How much financial support was provided in
2017? $ _____________ per ___________
9) Do you OR your listed dependent(s) receive any other
type of assistance or income?
(ex. WIC, Food Stamps, SSI,
Work First/TANF, etc.)
YES NO
If YES: Indicate the type and monthly amount:
Type: _____________ Amount: $_________
Type: _____________ Amount: $_________
Type: _____________ Amount: $_________
10) Did someone else claim you OR your listed
dependent(s) on their 2017 federal tax return?
YES NO
If YES: Name: _________________________
Relationship to you: _____________________
11) Will someone else claim you OR your listed
dependent(s) on their 2018 federal tax return?
YES NO
If YES: Name: _________________________
Relationship to you: _____________________
C. ADDITIONAL INFORMATION
Use the space below to provide any other information that may help explain how you provide the basic necessities (food, shelter,
utilities, clothing, personal items, etc.) for your listed dependent(s).
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
____________________________________________________________________________________________________________________
~If more space is needed, attach a separate sheet of paper that includes your name and WCC ID #. ~
D. CERTIFICATION AND SIGNATURE
By signing below, I certify that all information reported on this form and any documentation provided is true and complete.
__________________________________________________ _______________________
STUDENT SIGNATURE (REQUIRED)
DATE
WARNING: If you purposely provide false or misleading information to obtain financial aid, you may be fined, sentenced to jail, or both.
