Fillable Dependent Student CERTIFICATION AND STATEMENT OF DEPENDENTS (OTHER (Lurleen B Wallace Community College)

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Dependent Student CERTIFICATION AND STATEMENT OF DEPENDENTS (OTHER (Lurleen B Wallace Community College)

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10/10/2019
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to
jail, or both.
Dependent Student
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.
Full Name
Age
Relationship
Other Financial Assistance
Missy Jones (example)
15
Niece
Please explain why people listed above live your household and why they will receive financial support from
you:
I (We) certify that the above information is complete and correct (At least one parent must sign).
Student Date
Parent Date
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Dependent Student CERTIFICATION AND STATEMENT OF DEPENDENTS (OTHER (Lurleen B Wallace Community College)

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Completed 2 February 2021

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