Fillable 2021-2022 Students with Dependents Form (Eastern Wyoming College)

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2021-2022 Students with Dependents Form (Eastern Wyoming College)

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Financial Aid Office
3200 West C Street
Torrington, WY 82240
p: 307.532.8224
f: 307.532.8222
financialaid@ewc.wy.edu
2021-2022
Students with Dependents Form
You indicated on your Free Application for Federal Student Aid (FAFSA) that you provide more than 50% of financial support to
one or more children or other dependents. Since your answer determines your dependency status, we must verify your household size
and income. If there are differences, your FAFSA information may need to be corrected and/or you may need to enter parental
information. You must complete and sign this worksheet, attach any required documents and submit to the Financial Aid Office.
___________________________________________________________ ____________________ __________________________
Last Name First Name M.I. EWC Student ID Number Social Security Number (last four digits)
___________________________________________________________ _______________________________________________
Mailing Address (include apartment number) E-mail Address
___________________________________________________________ _______________________________________________
City, ST, Zip Phone Number (include area code)
Fill in the information below about the household member(s) you will provide more than 50% of support for between July 1, 2021 and
June 30, 2022. INCLUDE YOURSELF, YOUR CHILDREN, AND ANY OTHERS WHO RECEIVE MORE THAN HALF OF
THEIR SUPPORT FROM YOU. List the name of the college other household member(s) will be attending if they are or will be
enrolled in an eligible degree, diploma, or certificate program at a school eligible for Title IV funds for at least six credits any
time between July 1, 2021 and June 30, 2022.
Full name of household member
Age
Relationship to student
College attending
Self EWC
Has anyone in your household (listed above) previously, or does anyone in your household currently receive benefits from any of the
following federal benefit programs? You may be asked to provide documentation of benefits received. Only 2019 and 2020 benefits are
reported on your 2021-2022 FAFSA, but more current info can help establish a 50%+ support test.
Yes/No Type(s) of Benefits
Mark Year(s) Received
2019
2020
2021
2022
Medicaid or Supplemental Security Income (SSI)
Supplemental Nutrition Assistance Program (SNAP)/Food Stamps
Free or Reduced Price School Lunch Program
Temporary Assistance for Needy Families (TANF)
Special Supplemental Nutrition Program for Women, Infants, and Children (WIC)
Aid to Families with Dependent Children (AFDC)
Low-Income Housing or Low Income Energy Assistance Program (LIEAP)
STUDENT INFORMATION
BENEFIT PROGRAMS
FAMILY INFORMATION
Please explain IN DETAIL what your living circumstances were in 2019. Because FAFSA information requires 2019 income
information which may not reflect your current situation, please also explain IN DETAIL what your living circumstances are
now. Whom do you live with and how do you support your child/ren and/or other dependents? Provide dates of your living circumstances
and detail any changes that occurred between 2019 and now. You may attach a separate sheet if needed.
Please note: In most cases, students living with parents cannot be considered to support a child or other dependents more than 50%,
cannot be considered independent, and therefore must include parental information on the FAFSA.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
DO NOT LEAVE ANY ITEM BLANK. If any item does not apply, enter “N/A” for Not Applicable where a response is requested, or
enter $0 in an area where an amount is requested. ALL AMOUNTS ARE ANNUAL. To determine the correct annual amount for each
item: If you paid or received the same dollar amount every month in 2019, multiply that amount by the number of months in 2019 you
paid or received it. If you did not pay or receive the same amount each month in 2019, add together the amounts you paid or received
each month. If more space is needed for any item, attach a separate page with your name, student ID #, and appropriate information.
Please list your living expenses and explain how they were met and by whom. Do not leave any field blank.
2019
Current Year
Paid by: (Self/Parent/Other Relative/Friend)
Bill/Expense
ANNUAL Amount ANNUAL Amount
2019 Current (if different from 2019)
Rent/Mortgage
$
$
Utilities
$
$
Food
$
$
Clothing
$
$
Transportation
$
$
Car Payments/Leases
$
$
Insurance (Auto/Home)
$
$
Recreation/Entertainment
$
$
Cell phone
$
$
Other:
$
$
Other:
$
$
LIVING CIRCUMSTANCES
INCOME INFORMATION
CERTIFICATION AND SIGNATURE
Please list your income available to pay expenses listed above for 2019. Do not leave any field blank.
ALL AMOUNTS ARE ANNUAL. To determine the correct annual amount for each item: If you paid or received the same dollar
amount every month in 2019, multiply that amount by the number of months in 2019 you paid or received it. If you did not pay or
receive the same amount each month in 2019, add together the amounts you paid or received each month. If more space is needed for
any item, attach a separate page with your name, student ID #, and appropriate information.
***Note: Additional information may be requested***
By signing this worksheet, I certify that all of the information reported is complete and correct. I also acknowledge that I have read and
agree to comply with all verification policies as stated by EWC in the College Catalog and on the EWC website. Failure to submit
information in a timely fashion may result in the application being filed as inactive with no further consideration and no federal
aid for the academic year.
Student signature: ___________________________________________________________ Date: _____________________________
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
10/2020
Money Available to Pay Bills:
Total 2019 ANNUAL Amount Current Year ANNUAL Amount
Student’s income from work
$
$
Spouse’s income from work
$
$
Income from work (other)
$
$
Pension/Retirement
$
$
Unemployment/Worker’s Comp
$
$
Untaxed Social Security
$
$
Supplemental Security Income
$
$
Child support received
$
$
Welfare/AFDC/TANF
$
$
SNAP (food stamps)
$
$
Other (please specify)
$
$
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2021-2022 Students with Dependents Form (Eastern Wyoming College)

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Completed 4 February 2021

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