2019-2020 DEPENDENCY REVIEW
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STUDENT NAME BRANDMAN ID NUMBER
This form is to request a review of extenuating circumstances regarding your dependency status. You must complete all questions on
this form. The Financial Aid Office may request additional information/documents for consideration of your review. Please complete a
2019-2020 Free Application for Federal Student Aid (FAFSA) prior to submitting this form.
Circumstances that alone or in combination, do not warrant a dependency override:
1. Parent refusal to contribute to educational costs
2. Parent unwillingness to provide information on the FAFSA or for verification
3. Parent(s) do not claim the student as a dependent for federal income tax purposes
4. Student demonstration of total self-sufficiency
Include all of the following documents with this form:
Third party documentation: A third party who knows your situation and can attest to your unusual circumstances,
such as a teacher, counselor, medical authority, member of the clergy, prison administrator, government agency, or
court.
A signed letter on letterhead or an official document such as a court order is required. Letters should include
contact information. Letters from family members, girlfriend/boyfriend or friend are not sufficient.
A typed, detailed letter describing your unusual circumstances and relationship with your parent(s) along with
supporting documents.
A copy of your signed 2017 federal tax transcript or if you are a non-filer provide 2017 W-2s. Alternatively, you may
use the IRS Data Retrieval Tool on the FAFSA application.
Please answer the following questions:
Where will you live in 2019?
off campus with parent(s)
Did your parent(s) claim you on their federal tax return
in 2017 or 2018?
yes no
Will your parent(s) claim you on their federal tax return
in 2019?
yes no
Did your parent(s) provide your health
insurance for 2017 or 2018?
yes no
Will your parent(s) provide your health
insurance for 2019?
yes no
CERTIFICATION STATEMENT
I CERTIFY THE SUBMITTED INFORMATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF.
PURPOSEFULLY GIVING FALSE OR MISLEADING INFORMATION MAY RESULT IN DISMISSAL AND REFERRAL TO THE U.S.
DEPARTMENT OF EDUCATION. I UNDERSTAND THAT IF MY APPEAL IS APPROVED, I MUST SUBMIT A STATEMENT EACH
SUBSEQUENT YEAR CONFIRMING THAT THE DOCUMENTED ADVERSE FAMILY CIRCUMSTANCES STILL EXIST.
STUDENT SIGNATURE DATE
Submit completed form and all supporting documents via the student portal OR
Fax: 866-659-1147 Mail: Brandman University, Financial Aid Office, Third Floor 16355
Laguna Canyon Rd, Irvine, CA 92618
click to sign
signature
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