WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to
jail, or both.
CERTIFICATION AND STATEMENT OF DEPENDENTS
(OTHER THAN CHILD OR SPOUSE)
Please complete this certification, sign and submit to the Financial Aid Office.
Student Name: Student ID Number:
Please list below dependents (other than your children or spouse) who currently live with you and you will
provide more than half of their support and will continue to provide more than half of their support from
July 1, 2020 through June 30, 2021.
Other Financial Assistance
Please explain why people listed above live your household and why they will receive financial support from
I (We) certify that the above information is complete and correct (At least one parent must sign).