SUNY Potsdam One Stop/Financial A
id 44 Pierrepont Avenue Potsdam, NY 13676
Phone: (315) 26
Fax: (315) 267-3067 email:
Student Name: Potsdam ID :
INSTRUCTIONS: You filed your financial aid application (FAFSA) as an independent student based on the fact that you
have children or other dependents that live with you and receive more than half of their support from you between July 1, 2020, and
June 30, 2021. Since this statement is the basis for your dependency status is it necessary for us to verify the response. Answer each
of the following questions. Additional information may be requested.
1. What is the name, birth date, and relationship of your dependent(s)? (List any others on back.)
Birth date: Relationship to you:
2. Will your dependent(s) continue to live with you for the entire school year? YES NO
3. Do you and/or your dependent(s) live with your parents?
If yes, how much rent do you pay to your parents monthly? __________________
If no, what is your current address?
Who lives at this address with you? List name, age, and relationship of each member of your household.
4. Who claimed you as a tax exemption in 2019?
5. Who will claim you as a tax exemption in 2020?
6. Who claimed your dependent as a tax exemption in 2019?
7. Who will claim your dependent as a tax exemption in 2020?
8. Who provides medical insurance for you?
9. Who provides medical insurance for your dependent?
10. List your current monthly income below: (DO NOT LEAVE ANY BLANKS, IF NONE ENTER ZERO)
Wages, salaries, tips $_________
_ Veteran’s Benefits $__________
Unemployment $__________ Social Security/SSI $__________
Child Support $__________ Public Assistance (ADC/AFDC) $__________
Disability payments $__________ Worker’s Comp $__________
Other (identify): $__________
11. Attach a signed copy of your 2019 Federal 1040 Income Tax Return.
12. Statement of Certification: I certify that all of the information reported on this worksheet
is complete and accurate to the best of my knowledge, and I will follow through on any
documentation requested. Warning: If you purposely give false or misleading
information you may be fined, sentenced to jail or both.
Student Signature Date
(Request parent info for FAFSA)
Initial: _________