2020–2021 Household Members
Example: Missy Jones
C. Certification and Signatures
Complete form electronically and then print, sign and return to address
Student Signature (signature required)
ignature (required if dependent student) OR Spouse Signature (required if
independent and married)
WARNING: If you purposely give false or misleading
information on this worksheet, you may be fined, sent to
prison, or both.
We are requesting clarification of household information reported on your 2020–2021 Free Application for Federal Student Aid (FAFSA). The
that before disbursing your financial aid, we may ask you to confirm the information reported on your FAFSA. To verify that you reported correct and
complete information, we will compare your FAFSA with the information on this form and with any other required documents. If there are differences,
your FAFSA information may need to be corrected. In addition, you may be asked to provide other information.
A. Student’s Information
Student’s Last Name
Student’s First Name Student’s M.I.
Student’s Permanent Street Address (include apt. no.)
State Zip Code
4 digits of Social Security Number
Student’s Email Address
Student’s Alternate or Cell Phone Number
Per FAFSA, if you are an independent student, answer below as it
applies to your household. Include the name, age, and relationship for
• Student's Spouse (if married)
• Student's or spouse's children, if the student or spouse will provide
more than half of the children's support
• Other people if they now live with the student and the student or
spouse provides more than half of the other person's support
Per FAFSA, if you are a dependent student, answer below as it
applies to your parent(s) household. Include the name, age, and
relationship for the:
• Student's Parent(s) (as reported on the FAFSA)
• The parents’ other children if your parents will provide more
than half of the children's support
• Other people if they now live with your parents and your parents
provide more than half of their support
Name of College
Will be enrolled at least
half time (6 credits)?
In addition to name, age, and relationship to the student, if any household members will be enrolled in a degree, diploma, or certificate program at a
postsecondary educational institution at any time between July 1, 2020 and June 30, 202
1, please also indicate the name of the college and whether or
not the household member will be enrolled at least half time in the last two columns below. If not applicable, please leave the last two columns blank.
If more space is needed, attach a separate page with the student’s name and ID Number at the top.
B. Household Members Before responding below, consider the following definitions:
An independent student is one of the following: at least 24 years old, married, a graduate or professional student, a veteran, a member of the armed
forces, an orphan, a ward of the court, someone with legal dependents other than a spouse, an emancipated minor or someone who is homeless or at
risk of becoming homeless. A dependent student is someone who does not meet any of the criteria for an independent student. For questions regarding
your dependency status, please contact the financial aid office at email@example.com or 610-861-1330.
Report information below as it applies to your household any time between July 1, 2020 and June 30, 2021.
Please return your completed form to the Office of Financial Aid Services via:
Mail (1200 Main Street Bethlehem, PA 18018)
Electronically though Xmedius SendSecure
In-person (1st floor Colonial Hall)
Please complete this form electronically, and then print, sign and return to the Office of Financial Aid Services