Fillable 2019-20 Household Dependents Form (Eastern Florida State College)

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2019-20 Household Dependents Form (Eastern Florida State College)

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The 2019-20 Household Dependents Form (Eastern Florida State College) form is 2 pages long and contains:

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  • 7 check-boxes
  • 15 other fields

Country of origin: US
File type: PDF

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* This form must be submitted by the priority deadline to ensure a determination of eligibility before the Fee Due Date. Students may still apply
for aid after the priority deadlines, but EFSC cannot guarantee that late submissions will be notified of aid eligibility prior to the Fee Due Date.
01/30/19
20HDI
FA Verification
2019-20 Household Dependents Form
Independent Student
You included dependent(s) in your household between the ages of 24 and 64 on your verification form.
This form is required to determine if the individuals you listed meet the definition of dependent household members.
Complete a separate form for each dependent between the ages of 24 and 64 you listed on your verification form.
Priority Deadlines*: Fall 2019 – 07/18/19 | Spring 2020 – 11/25/19 | Summer 2020 – 04/23/20
A. Student Information
B#
Last Name First Name M.I. Student ID
B. Dependent in Your Household
Federal financial aid regulations define “dependents” as children or other persons who live in your household and
will receive more than 50% of their living expenses and other financial support from you between July 1, 2019 and
June 30, 2020.
Name of Dependent:
Age of Dependent:
Relationship to Student:
1. Will you provide more than 50% of the support to this individual from July 1, 2019 to June 30, 2020?
☐ YES – Go to Question 2.
☐ NO – Skip to Section D to sign the form. This person does not belong in your household and will be
excluded during the verification process.
2. Is this person a child attending college at least half-time in the 2019-20 academic year?
☐ YES – Skip to Section D to sign the form.
☐ NO – Go Question 3.
3. Will this person continue to live at the same address as you until June 30, 2020?
☐ YES – Complete Section C.
☐ NO – Skip to Section D to sign the form. This person does not belong in your household and will be
excluded during the verification process.
4. Do you want to exclude this person from your household?
☐ I no longer wish to include this person in the household. – Skip to Section D to sign the form.
EFSC will reduce the reported household size accordingly.
EFSC Office of Financial Aid
www.easternflorida.edu/go/aid | (321) 433-7339 | finaid@easternflorida.edu
2
C. Income Sources
Report all income sources received by the dependent. Do not leave any income source blank. If the dependent does
not
receive income from the listed source, put a "0" (zero).
Source of Income
Amount of Income
Temporary Assistance to Needy Families (TANF)
Amount received per month
Social Security
Amount received per month
Income from Work
Amount received per month
Unemployment Benefits
Amount received per month
Financial Aid (grants, loans, & scholarships) in excess of tuition and fees
Estimated monthly amount to be received in 2018-19:
Other sources of income (please specify):
Amount received per month
TOTAL
D. Certification and Signatures
By signing below I certify that all of the information reported is
compete and correct.
Student’s Original Signature (cannot be signed electronically) Date
WARNING: If you purposely give false
or misleading information, you may be
fined, sent to prison, or both.
EFSC Office of Financial Aid
www.easternflorida.edu/go/aid | (321) 433-7339 | finaid@easternflorida.edu
3
E. Document Submission
You may submit this document by the following methods:
1. EFSC DOCUMENT DROPBOX (RECOMMENDED)
Print and complete this document (including the original signature), scan the document, and upload the
document via the Document Dropbox in myEFSC. Printers and scanners are available in EFSC’s open
computer labs and libraries.
2. IN PERSON
Submit your document in person at the Office of Financial Aid on any campus:
Cocoa
Building 11, Room 209
Monday through Thursday, 8 a.m. to 7 p.m.
Palm Bay
Building 1, Room 117
Monday through Thursday, 8 a.m. to 7 p.m.
Melbourne
Building 1, Room 137
Monday through Thursday, 8 a.m. to 7 p.m.
Titusville
Building 3, Room 125
Monday through Wednesday, 8 a.m. to 5:30 p.m.
Thursday, 8 a.m. to 7 p.m.
3. BY MAIL
Mail your document to the Office of Financial Aid on any campus:
Eastern Florida State College
Office of Financial Aid, C11-209
1519 Clearlake Road
Palm Bay
Eastern Florida State College
Office of Financial Aid, PB1-117
250 Community College Parkway
Palm Bay, FL 32909
Eastern Florida State College
Office of Financial Aid, M1-137
3865 N. Wickham Road
Titusville
Eastern Florida State College
Office of Financial Aid, T3-125
1311 N. US 1
Titusville, FL 32976
QUESTIONS?
Financial Aid Specialists are available at the campus locations listed above, by phone at 321-433-7339, and via e-mail at
finaid@easternflorida.edu.
Eastern Florida State College is committed to equal access/equal opportunity in its programs, activities, and employment. For
additional information, visit Eastern Florida State College:
easternflorida.edu/go/equity.
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2019-20 Household Dependents Form (Eastern Florida State College)

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Completed 21 July 2020

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