Fill - Free fillable DEPENDENCY CHANGE REQUEST FORM 2020-2021 (Temple College) PDF form

2020-2021 Revised 10/01/19

DEPENDENCY CHANGE REQUEST FORM

2020-2021

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

The law governing the Federal Student Aid (FSA) programs is based on the premise that the family is the first source of the

student’s support, and the law provides several criteria that decide if the student is considered independent of his parents for

aid eligibility. For the 2020-2021 year, the criteria to be considered an independent student on the Free Application for Federal

Student Aid (FAFSA) include one or more of the following:

1) Born before January 1, 1997,

2) Married on the date the FAFSA is signed,

3) Working on a Master’s or Doctorate program,

4) A Veteran or currently serving on active duty in the US Armed Forces for purposes other than training,

5) Having dependents other than a spouse in which YOU provide over half their financial support,

6) At any time since the age of 13, you were an orphan, foster child, or ward/dependent of the court,

7) A State Court determined you were an emancipated minor when reaching the age of majority in your state of legal

residence,

8) A State Court determined someone other than your parent have legal guardianship of you, or

9) You were determined by a third party official, at any time since July 1, 2019, that you were an unaccompanied

youth who was homeless or self-supporting and at risk of being homeless.

If you do not meet at least one of the above criteria, you must complete the FAFSA as a dependent student and

include your parent’s information.

In order for our office to consider this appeal, you must document an extreme, unique and/or unusual family circumstance

which prevents you from obtaining parental information.

WHAT DOES NOT CONSTITUTE UNUSUAL CIRCUMSTANCES:

 Student lives apart from his or her parents

 Student lives with a roommate and “pays half of the bills.”

 Student demonstrates total self-sufficiency and does not receive financial support from their parents

 Parents do not claim the student as a dependent for federal income tax purposes

 Parents refuse to contribute to the student’s education

 Parents unwilling to provide information on the FAFSA application or for verification purposes

WHAT DOES CONSTITUTE UNUSUAL CIRCUMSTANCES:

 Hostile, abusive family environment

 Total abandonment by parents

 Incarceration

If there are unusual circumstances that may warrant re-evaluation of your dependency status, provide the required

documentation so the Financial Aid Office may make this determination. You may be asked for additional documentation

depending on your individual situation. The Financial Aid Director has the final authority to determine what circumstances can

and cannot be considered unusual.

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

If one of the circumstances below applies to you, please check the box to the left and provide all required documentation.

□ A severe situation exists in your family which may be the result of physical abuse, emotional abuse, parent(s) drug or

alcohol abuse, abandonment, parental incarceration or other unusual situations beyond your control.

Required documentation:

a. Completed Dependency Change Request form

b. Three Reference forms completed by third party persons explaining the situation in detail

c. Police reports, court reports, and/or documentation from a social agency

□ Your custodial parent has died and the other natural parent is still living; however, you have not had contact with nor

received financial support from the living parent for a significant period of time. (more than two years)

Required documentation:

a. Completed Dependency Change Request form

b. A copy of the death certificate for the deceased custodial parent

c. Three Reference forms completed by third party persons which support your claim that you have neither lived with

nor received financial support from the non-custodial parent for a significant length of time (more than two years)

Third party persons include:

 Minister

 Social worker

 Psychologist

 High School Counselor

 Teacher

 Doctor

 Other Professional

 Relative (only one Reference form may be from a relative)

Attach this completed form, all required documentation, and a signed copy of your two most recent federal income tax

returns and submit to:

Temple College

Financial Aid Office

2600 South First Street

Temple, TX 76504

The Financial Aid Office will review your appeal based on the documentation you provide, and you will be notified of the

results. An appeal submitted without proper documentation will be denied. The Financial Aid Office’s decision is final and

cannot be appealed to the U. S. Department of Education.

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

You must complete ALL sections in order for your request to be considered.

SECTION I: RESIDENCE INFORMATION

Current Address*: ____________________________________ Telephone Number: ______________________

____________________________________

How long at this address? From: ______/______ To: ______/______

Do you live with a relative? No ______ Yes ______ If yes, provide name of relative: __________________________

Do you live with a roommate? No ______ Yes ______ If yes, provide name of roommate: _______________________

If less than 2 years at current address, give prior addresses and time periods.

Address: ______________________________________ Address: ______________________________________

______________________________________ ______________________________________

From: ______/______ To: ______/______ From: ______/______ To: ______/______

* You may be asked to provide a copy of your current lease/housing agreement.

SECTION II: EMPLOYMENT HISTORY

Current Employer**: _________________________________________ Telephone Number: ______________________

Address: ___________________________________________________________________________________________

Employment dates? From: ______/______ To: ______/______

If less than 2 years at current employer, give previous employer(s).

Employer: ____________________________________ Employer: ______________________________________

Address: ____________________________________ Address: ______________________________________

____________________________________ ______________________________________

From: ______/______ To: ______/______ From: ______/______ To: ______/______

**You may be asked to provide a letter from your current employer indicating status, average hours/week, rate of pay, and length of

employment.

SECTION III: TAX INFORMATION

Did you file a federal income tax return for 2019? No _____ Yes _____ If yes, you must provide a signed copy of the return.

Did you file a federal income tax return in 2018? No _____ Yes _____ If yes, you must provide a signed copy of the return.

If you will not file a 2019 federal income tax return, explain how you supported yourself during 2018 and how you will continue to

support yourself in 2019: _____________________________________________________________________________________

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

___________________________________________________________________________________________________________

SECTION IV: INCOME & EXPENSES

Please complete the following tables of your annual income and expenses.

DO NOT LEAVE ANY BLANKS! Enter "ZERO" if the amount is zero and "NA" if it does not apply to your

circumstance.

ANNUAL INCOME RESOURCES

2019

2020 Estimated

1

Income earned from work (wages, salaries, tips, and any income from

work)

$

2

Untaxed Social Security benefits

$

3

AFDC / TANF (welfare benefits)

$

4

SNAP benefits

$

5

Financial support received from parents

$

6

Monetary value of other support (e.g., health insurance, room and

board) received from parents

$

7

Financial support received from another family member

$

8

Financial support received from a non-relative

$

9

Amount of other annual income (indicate source)

$

TOTAL ANNUAL INCOME (add items 1 - 9)

$

ANNUAL EXPENSES

2019

2020 Estimated

1

Housing

$

2

Food

$

3

Transportation (e.g., car payments, insurance, gas, maintenance)

$

4

Utilities

$

5

Personal (e.g., clothing, entertainment)

$

6

Other - indicate type of expense: _______________________

$

7

Other - indicate type of expense: _______________________

$

8

Other - indicate type of expense: _______________________

$

9

Other - indicate type of expense: _______________________

$

TOTAL ANNUAL EXPENSES (add items 1 - 9)

$

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

SECTION V: SUMMARY OF STUDENT’S SPECIAL CIRCUMSTANCE FOR DEPENDENCY CHANGE

Please explain briefly what your circumstances are for requesting a change in your dependency status:

SECTION VI: THIRD PARTY STATEMENTS

Please attach three supporting reference statements from three third party persons, such as school counselors, clergy

members, social workers, etc., who are familiar with your situation. These should come from individuals with a

“professional” association with the student. The statement must include their address, telephone number, and relationship

to student. Please use the attached reference forms for this purpose.

SECTION VII: CERTIFICATION & SIGNATURE REQUIREMENT

CERTIFICATION:

I certify that to the best of my knowledge all of the information provided on this form and all attached documents is true and complete.

If asked by an authorized official I agree to give proof of the information that I have given on this form. I realize that if I do not give

proof when asked this request may not be processed for financial aid.

I authorize the Temple College Financial Aid Office to discuss my situation with the individual(s) submitting any supporting

statement(s).

Student’s (handwritten) Signature: __________________________________________________ Date: ______________

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

FOR OFFICE USE ONLY

Is there a prior year dependency override processed? Yes ______ No ______

Dependency override decision: Approved __________ Denied __________

Reason for Approval / Denial: ___________________________________________________________________________________

___________________________________________________________________________________________________________

Financial Aid Administrator’s Name: ____________________________________________ Title: _______________________

Financial Aid Administrator’s signature: ______________________________________________ Date: _______________

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

DEPENDENCY CHANGE REQUEST – REFERENCE

1. How long have you known the applicant (student)? __________________________________________________

2. Are you related to the applicant? No _____ Yes _____ If yes, how are you related? __________________

3. With whom does the applicant reside? _____________________________________________________________

4. To your knowledge, has anyone, other than applicant's spouse, claimed the applicant as an income tax exemption for the

following years:

2019 Do not know ____ No _____ Yes _____ If yes, who? ___________________________

2018 Do not know ____ No _____ Yes _____ If yes, who? ___________________________

5. Please explain what you know to be the applicant's situation. Please be specific as the parent’s unwillingness to assist the

student is not grounds for a dependency change. If you need more space to explain, please attach a letter or use the back

of this form.

I certify that all the information on this form is true and complete to the best of my knowledge. I also understand that I may

be contacted if further information is needed.

Name of Reference (please print) _______________________

Street Address, P.O. Box, Etc. __________________________

City/State/Zip ______________

Official Title or Relationship to Applicant _________________________________

Telephone ( ) _________________________ Best time to be reached: ___________________

Signature of Reference ________________________________________ Date________________________

Return completed form to: Temple College

Office of Financial Aid

2600 South First

Temple, TX 76504

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

DEPENDENCY CHANGE REQUEST – REFERENCE

1. How long have you known the applicant (student)? __________________________________________________

2. Are you related to the applicant? No _____ Yes _____ If yes, how are you related? __________________

3. With whom does the applicant reside? _____________________________________________________________

4. To your knowledge, has anyone, other than applicant's spouse, claimed the applicant as an income tax exemption for the

following years:

2019 Do not know ____ No _____ Yes _____ If yes, who? ___________________________

2018 Do not know ____ No _____ Yes _____ If yes, who? ___________________________

5. Please explain what you know to be the applicant's situation. Please be specific as the parent’s unwillingness to assist the

student is not grounds for a dependency change. If you need more space to explain, please attach a letter or use the back

of this form.

I certify that all the information on this form is true and complete to the best of my knowledge. I also understand that I may

be contacted if further information is needed.

Name of Reference (please print) _______________________

Street Address, P.O. Box, Etc. __________________________

City/State/Zip ______________

Official Title or Relationship to Applicant _________________________________

Telephone ( ) _________________________ Best time to be reached: ___________________

Signature of Reference ________________________________________ Date________________________

Return completed form to: Temple College

Office of Financial Aid

2600 South First

Temple, TX 76504

Student’s Name (PRINT): ________________________________________ Student ID#: _____________

2020-2021 Revised 10/01/19

DEPENDENCY CHANGE REQUEST – REFERENCE

1. How long have you known the applicant (student)? __________________________________________________

2. Are you related to the applicant? No _____ Yes _____ If yes, how are you related? __________________

3. With whom does the applicant reside? _____________________________________________________________

4. To your knowledge, has anyone, other than applicant's spouse, claimed the applicant as an income tax exemption for the

following years:

2019 Do not know ____ No _____ Yes _____ If yes, who? ___________________________

2018 Do not know ____ No _____ Yes _____ If yes, who? ___________________________

5. Please explain what you know to be the applicant's situation. Please be specific as the parent’s unwillingness to assist the

student is not grounds for a dependency change. If you need more space to explain, please attach a letter or use the back

of this form.

I certify that all the information on this form is true and complete to the best of my knowledge. I also understand that I may

be contacted if further information is needed.

Name of Reference (please print) _______________________

Street Address, P.O. Box, Etc. __________________________

City/State/Zip ______________

Official Title or Relationship to Applicant _________________________________

Telephone ( ) _________________________ Best time to be reached: ___________________

Signature of Reference ________________________________________ Date________________________

Return completed form to: Temple College

Office of Financial Aid

2600 South First

Temple, TX 76504

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Fillable DEPENDENCY CHANGE REQUEST FORM 2020-2021 (Temple College)

Fill Online, Printable, Fillable, Blank DEPENDENCY CHANGE REQUEST FORM 2020-2021 (Temple College) Form

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