- 1 - Revised December 2019
Edison State Community College
2020-2021 Dependency Status Appeal Form
Student Name: _____________________________________________ SSN: _______________________________
(Last, First, Middle)
Student ID: ____________________________
Statement of Purpose
The basic premise of federal financial aid is that students and parents have the
primary obligation to finance post-secondary education to the extent that they are
able. This form is to be used by those financial aid applicants who are seeking a
review of their dependency status based upon circumstances not addressed in
current federal dependency definitions.
The information requested on this form will be reviewed by the Office of Student
Financial Aid. All supporting documentation should be attached to this appeal
form.
To appeal your dependency status you must do the following:
01. Write and Sign the Statement. Complete the enclosed student statement explaining the
reason why you should be considered an independent student. Also, document two years
of self-support by submitting IRS tax return transcript(s), apartment rent receipts, etc.
02. Collect Documentation. Submit appropriate third-party documentation from a professional
(counselor, physician, lawyer, clergy, etc.) which verifies your estrangement from your
parents or your parents’ unavailability to help you in this application process.
NOTE: Appeals submitted without appropriate third-party documentation will not be reviewed.
03. Submit Appeal And All Required Documentation. Submit third-party documentation along
with this appeal to the Office of Student Financial Aid as soon as possible after receipt of
your letter of ineligibility.
You will be notified in writing (either postal mail or Edison email) regarding any decision on
your appeal.
- 2 - Revised December 2019
Student Statement
Student Name: Student ID #:
Explain the reasons why you should be considered an independent student
List the documentation you have provided to support your explanation
I certify that all of the information and documentation that I have submitted pertaining to this
appeal is true and complete.
Student Signature: Date:
**Be certain to include all third-party, professional documentation in support of your situation.**
click to sign
signature
click to edit
- 3 - Revised December 2019
Confirmation of Self-Support
2019
I have filed a 2019 Tax Return. (Submit a copy of your 2019 IRS Tax Return Transcript with this application.
Include all schedules.)
I have NOT filed a 2019 Tax Return. (If you were not required to file a 2019 US Income Tax Return, you must
itemize how you supported yourself.)
I received the following non-taxable or other income for 2019:
TOTAL YEARLY AMOUNT of Social Security Benefits for 2019: $ __________________
TOTAL YEARLY AMOUNT of ADC or AFDC for 2019: $ __________________
TOTAL YEARLY AMOUNT of Child Support for 2019: $ __________________
TOTAL YEARLY AMOUNT of other untaxed income for 2019 (please explain): $ __________________
_______________________________________________________________________________________
_______________________________________________________________________________________
**If your total income was less than $8,000 for 2019, please explain how you supported yourself:
_______________________________________________________________________________________
_______________________________________________________________________________________
2018
I have filed a 2018 Tax Return. (Submit a copy your 2018 IRS Tax Return Transcript with this application.
Include all schedules.)
I have NOT filed a 2018 Tax Return. (If you were not required to file a 2018 US Income Tax Return, you must
itemize how you supported yourself.)
I received the following non-taxable or other income for 2018:
TOTAL YEARLY AMOUNT of Social Security Benefits for 2018: $ __________________
TOTAL YEARLY AMOUNT of ADC or AFDC for 2018: $ __________________
TOTAL YEARLY AMOUNT of Child Support for 2018: $ __________________
TOTAL YEARLY AMOUNT of other untaxed income for 2018 (please explain): $ __________________
_______________________________________________________________________________________
_______________________________________________________________________________________
**If your total income was less than $8,000 for 2018, please explain how you supported yourself:
_______________________________________________________________________________________
_______________________________________________________________________________________
- 4 - Revised December 2019
For Office Use ONLY
Appeal Accepted
Appeal Denied
Comments:
FAA:
Date:
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