202 S. Halsted St.
Chicago Heights, IL 60411
Financial Aid Office
(708) 709-3735
Fax: (708) 709-3716
m:\stuserv\favaoffice\2015-16 forms\depend support.docx
2015-16 Dependent Support Form
Student’s Name: ___________________________________ ID# ___________________________
Your status for financial aid as an Independent student is based solely upon your indication that you have children or
other dependents who will receive more than half of their support from you from July 1, 2015 June 30, 2016. Since
you do not meet any of the other criteria to be considered independent, you must complete this form to
demonstrate how you will provide support for your children or other dependents. If you cannot demonstrate
support you will be considered a dependent student and your parent will need to complete and sign your FAFSA.
Please complete this form. Do not leave any questions blank. Return this form along with all requested supporting
documentation to the Financial Aid Office. The Financial Aid Office will review your information and determine if it is
sufficient to demonstrate support of a child or other dependent. If determined that you do not provide more than
half of the support for the child/dependent below, you will be considered a dependent student and will need to
update your FAFSA to include your parents’ information.
Name of Dependent
Relationship to You
1. Will the above dependent(s) receive more than half of his/her support from you from July 1, 2015
June 30, 2016?
Yes or No
2. Will your dependent(s) live in the same household as you July 1, 2015 June 30, 2016?
Yes or No
a. If yes, when did the dependent(s) start living with you?
Provide Date: ____________
3. Are you paying for child/daycare for your child / dependent?
Yes or No
a. If you answered yes, please provide the following:
i. Child/daycare receipts in your name or
ii. Statement of account with care provider in your name or
iii. Document dependent(s) care received through a state or government program.
Turn Over to Complete
4. Are you providing medical coverage for your dependent(s)?
Yes or No
a. If yes, attach a copy of medical coverage card
b. Answer yes if your child has Medicaid through a government program and attach a copy
of the medical coverage card.
5. Does your dependent(s) receive any income or support on their behalf during 2014 and/or
Yes or No
Support includes but not limited to (Attach documentation):
TANF WIC SNAP SSI/SSA Income Earned from Work
Child Support Other: _____________
Please outline how you provide basic necessities (food, clothing, diapers, personal items, etc.) for your
dependent(s). Be specific and detailed! Attach another sheet if necessary.
I certify that I have read and understand all items on this form and all information provided for my
financial aid is true and correct
Student’s Signature _______________________________________ Date _____________________
click to sign
click to edit