L. C. BOX 582, PINEVILLE, LA, 71359
PHONE: 1-318-487-7386 FAX: 1-318-487-7449 E-MAIL:
2020-2021 Documentation of
Independent Student Status Legal
Dependent Form
Student Information:
First name_______________________ Last name______________________ Date_________________
Address ____________________________ Date of Birth_________ SSN or Student ID_____________
Provide the following information about the dependent:
Full Name____________________________ Age______ Relationship to Student
City State ZIP
Documentation Required:
A copy of the dependent’s birth certificate (available from the Bureau of Vital Statistics of the
child’s state of birth.) Hospital birth records or certificates are not acceptable documentation.
A signed copy of your 2018 federal income tax return if you claimed your dependent as an
exemption. (By claiming your dependent on your income tax return, you are confirming to the
Internal Revenue Service that you are the supporting parent/guardian. Therefore, the Office of
Financial Aid will accept this as corroboration for the financial support of your dependent that
FAFSA requires for you to be considered an independent student.)
o If you did not claim your dependent as an exemption please check which box
applies to you AND submit the Legal Dependent Monthly Expense Report.
o I have a court order which gives another party the right to claim my dependent
in alternating years (please submit a copy of the court order). I did not/will not claim
my dependent child for other reasons.
o My dependent was born on or after January 1, 2019.
By signing this document, I certify that all of the information reported on it is complete and correct to
the best of my knowledge. I also understand that if I purposefully give false or misleading information
on this document, I would be violating Federal statute and could face penalty.
Student Signature Last 4 of Social Security #
click to sign
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