Evaluation of Support for Child or Dependent
Complete this entire form if you have been notified on your To-Do list that you are required to verify financial support of your dependent.
Incomplete forms or conflicting information will cause delays in the processing of your aid. Instructions for looking up your Student I.D.
can be found here: Find your student ID here.
A. Student Information
Last Name: _____________________________________ First Name: __________________________________________
Student ID (required): ________________Date of Birth: __________________ Phone Number: _____________________
B. Dependent Information
Dependent Name: ______________________________ Age: __________ Relationship to Student: ____________________
Does the dependent live with you for at least 6 months and 1 day per year? Yes: No:
If dependent is over 15, does he/she work? Yes: No: If yes, annual income $_____________
Please attach proof of income (most recent paycheck stubs, most recent W-2, most recent taxes filed, etc.)
C. Student’s Financial and Expense Information
Student’s annual income: $____________ Please attach proof of income (most recent paycheck stubs, most recent W-2, most
recent taxes filed, etc.)
Do you receive any of the following? WIC benefits: Yes No
SNAP: Yes No Monthly amount $ _________
Housing assistance from a federal, state, or local program: Yes No Monthly amount $ _________
Do you receive any other financial assistance from a federal, state, or local source? Yes No if yes, please specify:
Source ____________________ Monthly amount $ ________ Source ____________________ Monthly amount $ ________
Source ____________________ Monthly amount $ ________ Source ____________________ Monthly amount $ ________
Housing situation: Own home: Rent home: Live with Family:
Other: (specify) __________________________________ Monthly housing payment paid by the student: $ ___________
Please give the average monthly amount of the household expenses paid by you, the student (e.g. electric, gas, water,
telephone, child care, car payment, other required monthly payments such as loans, insurance, etc.) Please provide receipts or
a copy of your bank statement indicating payments made.
D. Certification and Signatures
I certify that all the information reported on this worksheet is complete, correct, and any additional information is attached.
Student Signature: ________________________________________ Date Signed: _____/______/_______
Please return this completed form in one of the following ways; fax to 540-234-8189, scanned e-mail attachment to finaid@brcc.edu, or mail to
Blue Ridge Community College, Office of Financial Aid, Box 80, One College Lane, Weyers Cave, VA 24486. Please call 855-844-3631 if you
have questions.
