DSCC Financial Aid Office
DEPENDENCY OVERRIDE REQUEST
Name:
Student ID:
Address:
Street/P.O. Box City State Zip
E-mail Address: ________ Phone: ( ) - ______
Section 480(d) of the Higher Education Act (HEA), defines an independent student as someone who meets one of the
eight criteria specified in the HEA and reflected on the Free Application for Federal Student Aid (FAFSA) or is a student for
whom a financial aid administrator makes a documented determination of independence by reason of other unusual
circumstances.
The Higher Education Act allows an aid administrator to make dependency overrides on a casebycase basis for
students with unusual circumstances. NONE of the conditions listed below, singly or in combination, qualify as unusual
circumstances or merit a dependency override:
1. Parents refuse to contribute to the students education;
2. Parents are unwilling to provide information on the FAFSA or for verification;
3. Parents do not claim the student as a dependent for income tax purpose;
4. Student demonstrates total selfsufficiency.
If you can document why you should be considered independent for some unusual reason, you may request a
dependency override. Please check reason for request:
1. Voluntary or involuntary removal from parents’ home due to an abusive situation that threatened the
student’s safety and/or health
2. Incapacity of parents such as incarceration or a disability or mental or physical illness
3. Inability of the student to locate the parent(s) after making reasonable efforts
4. Other extenuating circumstances sufficiently documented by a signed letter from a third party.
Acceptable documentation could be a court order, police report, legal document or a letter from clergy, high school
guidance counselor or teacher and relative that is aware of your situation.
You must complete the Free Application for Federal Student Aid (FAFSA) and submit it along with copies of any
information used to complete it (such as income tax returns, W2s, and documentation of untaxed income). If your
FAFSA has already been submitted to the Department of Education, make sure Dyersburg States school code (006835)
was on it so they can transmit your processed information to us.
PLEASE COMPLETE THIS FORM AND ATTACH YOUR WRITTEN EXPLANATION AND DOCUMENTATION.
Due to the high volume of work in August and January, a decision may take up to 30 business days. (This request will
not be processed if supporting documentation is not attached). You will be notified via Dyersburg State email
or letter of the decision regarding your request.
The law also requires that a determination of unusual circumstance(s) must be made each award year. A determination
of independence in one award year does not mean that you would automatically be an independent student in a
subsequent award year. You must request the dependency override in the subsequent year again if you are not
automatically an independent student according to FAFSA criteria. The Financial Aid Office must affirm that the
conditions for determining you to be independent continue to exist and continue to make expecting a parental contribution
inappropriate.
By signing this statement, I certify that all information submitted is true and correct to the best of my
knowledge. Misrepresentation of information may result in repayment of federal and state financial aid
received.
Student’s
Signature:
Date:
FOR FINANCIAL AID OFFICE USE
ONLY
Previous Status: Override:
Dependent
Independent
Approved:
Denied:
Comments:__________________________________________________________________________________________
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By:________________________________________________ Date:___________________________________________
PUB 06-11-207
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