STUDENT Enter YEARLY Amounts
_______________________________________ ________________________ _____________________
Office of Financial Aid
Waycross Campus (912) 287-6584
Jesup (912) 427-5800
Alma (912) 632-0951
Camden (912) 510-3327
Hazlehurst (912) 379-0041
Baxley (912) 367-1700
Golden Isles (912) 262-4999
Website: www.coastalpines.edu
Dependent Student
Household Members
Verification
Worksheet
Form: DVHM21
Aid Year: 2020-2021
Please Type o
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ly.
Student Information:
Full Name (last, first, and middle initial) CPTC – Student ID Number Date of Birth
Federal Student Aid Programs: Your application was selected for review in a process called “Verification.” In this process, the Office of Financial Aid will be
comparing information from your FAFSA application with you and your parent(s) financial documents. We are required to review your FAFSA information under
financial aid program rules (34 CFR, Part 668). The law states we have the right to ask you for this information before awarding Federal Aid. If there are differences
between your application information and your financial documents, corrections to your FAFSA may be required.
Family Information:
In the table below, include: ☐ Yourself ☐ Your parent(s) (including step-parent) even if you did not live with them ☐ Your parents’ other dependent (under age 24)
children, even if they don’t live with your parent(s), if your parents will provide more than half of their support from July 1, 2020 to June 30, 2021.
Include other people as part of your parents’ household ONLY IF: ☐ They now live with your parent(s), and your parent(s) provide more than half of their support, and
will continue to provide more than half of their support from July 1, 2020 to June 30, 2021. Documentation may be required.
List yourself first, then all household members. If any household member, excluding your parent(s) will be attending college at least half time, in a degree, diploma or
certificate program, include the name of the college. If you need more space, attach a separate page.
If attending college from 07/01/20 – 06/30/21, college name
Coastal Pines Technical College
Certification and Signature
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
Each person signing below certifies that all of the information reported is complete and correct. The student (and one parent whose information
was reported on the FAFSA, if a dependent student) must sign and date.
___________________________________________ _______________________________________
Student's Signature Date
___________________________________________ _______________________________________
Parent’s Signature (Required, if Dependent Student) Date
Do not mail this form to the Department of Education. Submit this worksheet to the Office of Financial Aid!
As set forth in the student catalog, Coastal Pines Technical College (CPTC) does not discriminate on the basis of race, color, creed, national or
ethnic origin, gender, religion, disability, age, political affiliation or belief, genetic information, veteran status, or citizenship status (except in
those special circumstances permitted or mandated by law). The following persons have been designated to coordinate the College’s
implementation of non-discrimination policies: Katrina Howard, Title IX Coordinator, Jesup Campus, Office 132, khoward@coastalpines.edu
,
912.427.5876; Cynthia Linder, Office 1439, Title IX Coordinator, Waycross Campus, clinder@coastalpines.edu , 912.287.4098; and Cathy
Montgomery, ADA/Section 504 Coordinator, Golden Isles Campus, Office 1141, cmontgomery@coastalpines.edu , 912.262.9995.
click to sign
signature
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