WARNING: According to the U.S. Department of Education, if you purposely give false or misleading information on form, you may be
subject to a fine of up to $20,000 or imprisonment for up to 5 years, or both.
Financial Aid Office - Eastern Oregon University - One University Blvd., Inlow Hall STE 104, La Grande, OR 97850-2807
Phone: (541) 962-3550 | Fax: (541) 962-3661 | E-mail: firstname.lastname@example.org | WWW: www.eou.edu/fao | Secure document upload: goo.gl/6Rolj0
Third Party Statement Form
This form should be completed and submitted with the student’s Dependency Override Request.
Student Name: ______________________________________ EOU SID Number: ___________________
This section is to be completed by the third party giving the statement:
How long have you known the student? _______________________________________________________
Relationship to the Student: ________________________________________________________________
Contact Telephone Number: ________________________________________________________________
Describe what you have observed regarding the circumstances leading up to the student’s estrangement
from his/her parents, the duration and whether or not he/she currently has contact with either of them.
Please have this form notarized below. Sign only in Notary's presence.
Signature: _______________________________________________ Date: ____________________
Notary Public’s Affidavit:
State of ___________________________________ City/County of __________________________________
On___________________, before me, _________________________________________, personally appeared,
(Date) (Printed Notary’s Name)
__________________________________, and provided to me on basis of satisfactory evidence of identification,
(Printed name of signer)
__________________________________, to be the above-named person who signed the foregoing instrument.
(Type & number of valid photo ID provided)
WITNESS my hand and official seal
(seal) Signature of Notary: ______________________________________
My commission expires on: _________________________________
If you need additional space, use the back of this form or attach additional page(s).