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(2021-2022 Academic Year) (Coconino Community College)

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  • 30 check-boxes
  • 13 other fields

Country of origin: US
File type: PDF

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2800 S Lone Tree Rd
Flagstaff, AZ 86005-2701
PH: 928-226-4219
FAX: 928-226-4110
finaid@coconino.edu
PRFDEP
FA-404-PRFDEP 2122 20201215
PROOF OF DEPENDENT FORM
(2021-2022 Academic Year)
On the FAFSA you indicated you have a child or dependent whom you provide at least half of their support.
Do you have a child or children?
Yes
No
If Yes, attach a copy of your child(ren)’s birth certificate showing you as the parent.
Are you pregnant?
Yes
No
If yes, you must attach a doctor’s statement confirming pregnancy and your due date occurring prior to
June 30, 2021.
Will your child(ren) receive more than
half of their support from you between
July 1, 2020 and June 30, 2021?
Yes
No
Do you have dependents (other than
your children or spouse) who live with
you and who receive more than half of
their support from you between July 1,
2020 June 30, 2021?
Yes
No If yes, please list their names and relationship to you:
_________________________________________________
_________________________________________________
Will you receive money from any of the following between July 1, 2021 and June 30, 2022?
Income from working?
Yes
No
Significant other?
Yes
No
Financial aid and/or scholarships?
Yes
No
SNAP (Food Stamps)?
Yes
No
Women, Infants and Children (WIC) Assistance?
Yes
No
Social Security Benefits?
Yes
No
Housing Assistance / Benefits (including Section 8 / low income housing)?
Yes
No
Medical Assistance (AHCCCS)
Yes
No
Supplemental Security Income (SSI)?
Yes
No
Welfare (including TANF)?
Yes
No
Other (list): _____________________________________________________________
(Unemployment, Disability, etc.)
Yes
No
I certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving false or misleading
information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent to prison or both. I hereby provide
consent for the use of electronic records and signatures on all financial aid documents. I understand that if I choose to sign electronically, my
electronic signature constitutes a binding contract and may not be denied legal effect, validity, or enforceability solely because it is in electronic
form or because an electronic signature or electronic record was used in its formation
Student's Signature and Date
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(2021-2022 Academic Year) (Coconino Community College)

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Completed 2 February 2021

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