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2020-2021
Proof of Dependents
STUDENT NAME: _____________________________________________ WCC ID: _______________________
ADDRESS:
________________________________________________ ___________________________________ ____________ _______________
STREET OR PO BOX CITY STATE ZIP
On the 2020-2021 FAFSA you replied that you [or, for dependent students, your parent(s)] provide more than half of the support for a
child OR other dependent(s). The Financial Aid Office requires verification of this support. PLEASE NOTE Your eligibility for
financial aid cannot be determined until the verification process is complete.
INSTRUCTIONS: You [or your parent, if requested] should complete this form using blue or black ink, attach relevant supporting
documentation, sign, and submit the completed package to the WCC Financial Aid Office for review. IMPORTANT Students
who do not meet federal guidelines for independent status and who are unable to provide acceptable documentation of providing
greater than 50% of the support for a qualified dependent will need to make corrections to the FAFSA to include parent information.
In the spaces below, list your qualified dependent(s). Documentation of the relationship is required (birth certificates, court documents, etc.)
Include your children if you will provide MORE THAN HALF of their support from July 1, 2020 through June 30, 2021, even
if the children
do not live with you.
Include other people ONLY if they meet all the following criteria:
1) They now live with you; AND
2) They currently receive MORE THAN HALF of their support from you; AND
3) They will continue to receive MORE THAN HALF of their support from you through June 30, 2021.
NOTE: Support includes money, housing, food, clothing, medical/dental care, transportation, payment of college costs, and similar expenses.
FULL NAME OF DEPENDENT(S)
ATTACH copies of birth certificates, court documents, etc.
AGE
LAST 4 DIGITS
OF SSN
RELATIONSHIP TO YOU
~if you need additional space, please attach a separate sheet of paper that includes the student name and WCC ID~
This form is being completed by: Independent Student Parent of a Dependent Student
Where is the STUDENT living?
In the student’s own house, apt. condo, etc.
(
ATTACH a copy of the lease, mortgage, or other
proof of housing in the student’s name)
With the child’s other parent
Name: ________________________________
With the student’s parent(s) Other: _______________________________________
Where is/are the DEPENDENT(S) named above living?
With the student
With the child’s other parent
With the student’s parent(s)
Other (please explain): ____________________________________________
Do you provide medical coverage for the DEPENDENT(S) named above?
Medicaid
No
(
ATTACH
a copy of the medical card)
Who provides medical coverage? ______________________
If you are an Independent Student, will you pay someone to care for your dependent(s) while you are attending class?
Yes
Amount Paid: $ __________ per ________
No
Who claimed the STUDENT on the 2019 federal tax return?
The student
The student’s parent(s)
Other: ___________________
Who claimed the DEPENDENT(S) named above on the 2019 federal tax return?
The student
The student’s parent(s)
Other: __________________
Not born until 2020
(if the dependent was claimed by the student or student’s parent(s), ATTACH a copy of the applicable 2019 federal tax return)
Did the DEPENDENT(S) named above file a federal tax return for 2019?
Yes (
ATTACH
a copy of the DEPENDENT’S 2019 tax return and W-2’s)
No
Who will claim the DEPENDENT(S) named above on the 2020 federal tax return?
Name: _________________________________________
Relationship to the dependent(s): ________________________
RETURN THIS COMPLETED FORM WITH REQUIRED DOCUMENTATION TO:
Wayne Community College - Financial Aid Office - PO Box 8002 - Goldsboro, NC 27533-8002
FAX: 919-736-9425
Wayne Community College is accredited by the Southern Association of Colleges and Schools Commission on Colleges to award associate degrees. Contact the Commission on Colleges at 1866
Southern Lane, Decatur, Georgia 30033-4097 or call 404-679-4500 for questions about the accreditation of Wayne Community College. The Commission on Colleges may be contacted only if there is
evidence that Wayne Community College is significantly non-compliant with a requirement or standard. Accreditation standards are located at: http://www.sacscoc.org/principles.asp. Inquiries about
Wayne Community College, such as admission requirements, financial aid, educational programs, etc. should be addressed directly to Wayne Community College and not the Commission’s office.
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Does the DEPENDENT(S) listed on page 1 receive earnings or benefits in his/her own name? (check all that apply)
Wages: amount $____________ per __________
Retirement: monthly amount $ ______________
Social Security/SSI: monthly amount $ _________
VA Benefits: monthly amount $ _____________
Public Assistance: type: ___________________
Other: amount $_____________ per _________
My dependent is not employed and receives no benefits
CURRENT MONTHLY INCOME/BENEFITS INFORMATIONdo not leave blank if an item does not apply to you, please enter -0- or N/A.
TYPE OF INCOME STUDENT
PARENT
[Dependent
Students Only]
ATTACH RELEVANT SUPPORTING DOCUMENTATION
Earnings from work
$
$
copy of the most recent pay stub
Unemployment
$
$
copy of current benefit statement
Social Security/SSI
$
$
copy of current benefit statement
Child Support RECEIVED $ $
proof of support received for all children for the past 12 months
(statement from child support agency, bank statements, copies of checks)
Work First/TANF
$
$
statement from DSS
SNAP/Food Stamps
$
$
copy of EBT card or statement from DSS
WIC
VOUCHER
VOUCHER
statement from DSS
TOTAL MONTHLY INCOME
$
$
Do you receive support from sources not included elsewhere on this form? (example: gifts, loans, etc. from family, friends, or others)
Yes
No
If yes, list the person who helps, relationship to the student, type of assistance, and amount provided each month:
Person/Relationship to Student
Type of Assistance
Amount per Month
___________________________________________________
_____________________________
$ _______________
___________________________________________________
_____________________________
$ _______________
___________________________________________________
_____________________________
$ _______________
CURRENT MONTHLY EXPENSES do not leave blank if an item does not apply to you, please enter -0- or N/A.
Monthly Expense Monthly Cost
Amounts Paid by:
If paid by “other”,
provide name & relationship
Student
Other
Housing (rent, mortgage, etc.)
$
$
$
Food (groceries, meals out)
$
$
$
Utilities (gas, water, electric)
$
$
$
Internet/Cable or Satellite TV
$
$
$
Phone (cell or landline)
$
$
$
Childcare/Dependent Care
$ $ $
Transportation (gas, car payment,
auto insurance, maintenance, or
mass transit expenses)
$ $ $
Child Support PAID
$
$
$
Other: ________________
$ $ $
TOTAL MONTHLY EXPENSES
$
$
$
supporting documentation may be required
CERTIFICATION AND SIGNATURE
By signing below, I certify that all information reported on this form and any documentation provided is true and complete.
_________________________________________
STUDENT SIGNATURE (REQUIRED)
_____________________
DATE
_________________________________________
PARENT SIGNATURE (REQUIRED FOR DEPENDENT STUDENTS)
_____________________
DATE
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