Fillable CHILDS PROOF OF DEPENDENCY AFFIDAVIT Dependents Name Dependent's (Case Western Reserve University)

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CHILDS PROOF OF DEPENDENCY AFFIDAVIT Dependents Name Dependent's (Case Western Reserve University)

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U.S.A. forms for Case Western Reserve University

BROWSE CASE WESTERN RESERVE UNIVERSITY FORMS

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CHILD’S PROOF OF DEPENDENCY AFFIDAVIT
Dependent’s Name
Dependent's 7-Digit Student ID Number
I certify that the above-named child, while not my tax dependent, is:
Please check the appropriate box under Section A and Section B
A.
My son or daughter (either natural or legally adopted),
OR
My stepson or stepdaughter,
OR
The son, daughter, stepson, or stepdaughter of my domestic partner and resides
within the household of the domestic partnership
OR
A child who has a court-appointed legal relationship with me, or my domestic
partner (i.e. adoption, guardianship, foster child) and who is a member of my
household
AND
B.
A child for whom I provide over one-half of his/her support;
OR
A child who:
a)
receives over one-half of his/her support from parents who are
divorced, separated, or living apart, and
b)
is in the custody of one or both or his/her parents for more than one-
half of the calendar year;
OR
A child who:
a)
receives over one-half of his/her support from parents (but neither
parent contributes over one-half of the support),
b)
Receives over 10 percent of his/her support from me, and
c)
Have neither received a waiver of dependency from anyone else who
contributes over 10 percent;
OR
A child:
a)
Who has not attained age 25, and
b)
Both of whose parents are deceased.
Employee’s Signature
Date
Rev. 07/2017
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CHILDS PROOF OF DEPENDENCY AFFIDAVIT Dependents Name Dependent's (Case Western Reserve University)

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Completed 13 January 2022

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