Please return this completed form and all other required materials to:
Ottumwa Campus: Indian Hills Community College, Attn. Financial Aid, 525 Grandview Avenue, Ottumwa, Iowa 52501
Fax: 641-683-5741, Phone: 800-726-2585, ext. 5262 or 641-683-5262, email us at: OneStop@indianhills.edu
Centerville Campus: Indian Hills Community College, 721 North First Street, Centerville, IA 52544
Fax: 641-856-3158, Phone: 800-670-3641, ext. 2200 or 641-856-2143, ext. 2200 email us at: OneStop@indianhills.edu
To check the status of your documents, go to WebAdvisor and click the Financial Checklist, under the Financial Aid heading.
2018-2019 VERIFICATION OF DEPENDENTS OTHER THAN SPOUSE OR CHILDREN
Student Name
Student ID or SSN
Independent -You have indicated that you have dependents other than your children or spouse, or are still
s
upporting children 24 years of age or older. Do you have dependents (other than your children or spouse) who live
with you and who receive more than half of their support from you, now and through June 30, 2019? Support
includes money, housing, food, clothes, medical and dental care, gifts, loans, payment of college costs, etc.
OR
Dependent - You have indicated that your parents have dependents other than their children or spouse, or are still
supporting their children 24 years of age or older. Do your parents have dependents who are not your parents’
children but who live with your parents and receive more than half of their support from your parents, and will
continue to receive more than half of their support from your parents, now and through June 30, 2019? Support
includes money, housing, food, clothes, medical and dental care, gifts, loans, payment of college costs, etc.
No
Select No if you/your parents do not have other dependents. Also, select No if you have other dependents,
but they will not be receiving more than half of their support from you/your parents while you are in college.
Skip to Certifications and Signatures.
YES
Select Yes if you/your parents have dependents (other than your/their children or spouse). In the chart
below, list
the people who meet the following criteria:
1) They live with you/your parents now
2) You/your parents provide more than half of their support, and
3) You/your parents will continue to provide more than half of their support from July 1, 2018 through June 30, 2019.
Full name of dependent
Age
Relationship to student
2. Check the box that applies:
The dependent was not employed and had no income earned from work in 2016.
The dependent was employed in 2016. Provide copies of all 2016 IRS W-2 forms issued by their employers. If
your dependents listed above have filed or will file a 2016 federal tax return, have them obtain their 2016 IRS
tax return transcripts.
Certifications and Signatures
E
ach person signing below certifies that all of the
information reported is complete and correct.
__________________________________________________________ ________________________
Student’s Signature (Required) Date
__________________________________________________________
________________________
Other Dependent Signature (Required unless minor) Date
__________________________________________________________
________________________
Parent’s Signature (if student is dependent) Date
WARNING: If you purposely give false or
misleading information, you may be
fined, sent to prison, or both.
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