Dependent Verification Worksheet
Coahoma Community College Office of Financial Aid
3240 Friars Point Road, Clarksdale, MS 38614
Fax: (662) 627-9871 Email: firstname.lastname@example.org
Student’s Last Name Student’s First Name CCC ID or Last four of SSN
Student’s Phone Number (include area code) Student’s Date of Birth
Student’s Family Information
Include: Yourself and your parent(s) (including a stepparent) even if you don’t live with the parents.
Your parent(s)’ other children if your parent(s) will provide more than half of their support from July 1, 2019 through
June 30, 2020.
Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will
continue to provide more than half of their support through June 30, 2020. Include the name of the college for any
household member, excluding your parent(s), who will be enrolled, at least half time in a degree, diploma, or certificate
program at a postsecondary educational institution any time between July 1, 2019, and June 30, 2020.
Relationship College Will be Enrolled at
Least Half Time?
Coco Tiger (example) 19 Self Coahoma Community College Yes
Certification and Signatures:
Each person signing this worksheet certifies that all of the information reported is complete and correct. The student and one parent
must sign and date
Student’s Signature Date
Parent’s Signature Date
Coahoma Community College is an equal opportunity institution in accordance with civil rights and does not discriminate on the basis of race, color, national
origin, gender, disability, age, or other factors prohibited by law in any of its educational programs, activities and employment opportunities. The following
person has been designated to handle inquiries regarding the non-discrimination policies: Michael Houston, Director of Human Resources/Coordinator for
504/ADA, Title IX Compliance Officer, Office #A100, Vivian M. Presley Administration Building, 3240 Friars Point Road, Clarksdale, Mississippi 38614,
Phone: (662) 621-4853, Email: email@example.com.
WARNING: If you purposely give false or
misleading information on this worksheet,
you may be fined, be sentenced to jail, or