1Office of Student Financial Aid Lamar State College Port Arthur
MEMBER THE TEXAS STATE UNIVERSITY SYSTEM
TM
5
PROOF OF LEGAL DEPENDENTS 2019-2020
Student’s Name __________________________________________ Student ID _________________________
1516_DEPOV_APPEAL FORMS
This information is being requested by the U.S. Department of Education due to you reporting on your
2019‐2020 FAFSA that you are supporting someone who will receive more than half of their support from you
between July 1, 2019 and June 30, 2020. Support includes money, housing, food, clothing, child care, and health
care. You must provide documentation of this support in order to qualify as an Independent Student. If
you do not provide over half of this person’s support, you will need to make corrections to your FAFSA
question #51 and provide your parent information, including their financial information and parent signature.
DEPENDENTSPlease list the names and ages of dependents included on your 2019-2020FAFSA:
Dependent’s Full Name
Age
Relationship to You
LIVING ARRANGEMENTS
1. Is your dependent primarily living with you through June 30th, 2020?
___No ___Yes - Attach a copy of your current lease. If no lease, attach explanation of living arrangements.
2. Are you living with your parents? ___No ___Yes
EXPENSES
3. Are you paying for childcare for your dependent?
___No ___Yes - Attach a letter from the provider confirming the child’s name and amount paid per month
4. Will you pay child support for your dependent?
___No ___Yes Amount you will pay from 7/1/19 thru 6/30/20: __________________________________________
YOUR INCOME
5. Are you employed? ___No ___Yes - Attach your most recent paystub
6. Will you receive child support for your dependent?
___No ___Yes - Amount you will receive from 7/1/19 thru 6/30/20: ________________________________________
IF YOUR DEPENDENT IS YOUR BIOLOGICAL CHILD
7. Are you or your dependent receiving support from your parents for your dependent’s care? (Support includes cash,
bills paid for you, supplies like food and diapers, and indirect support such as housing & insurance).
___No ___Yes TYPES: _________________________________________________________________________
Total estimated value per month: __________________
8. Are you or your dependent receiving support from anyone else, other than your parents, for your dependent’s care?
(Includes cash, bills paid for you, supplies like food and diapers, and indirect support such as housing & insurance).
___No ___Yes Provider’s Relationship to Dependent: __________________________________________________
TYPES: _____________________________________________________________________________
Total estimated value per month: __________________
IF YOUR DEPENDENT IS NOT YOUR BIOLOGICAL CHILD
9. Are you receiving support from someone else for your dependent’s care? (Includes cash, bills paid for you, supplies
like food and diapers, and indirect support such as housing & insurance). Please Provide Documentation.
___No ___Yes Provider’s Relationship to Dependent: __________________________________________________
TYPES: _____________________________________________________________________________
Total estimated value per month: __________________
10. Is your dependent receiving support from someone else for their care? (Includes cash, bills paid for you, supplies like
food and diapers, and indirect support such as housing & insurance). Please Provide Documentation.
___No ___Yes Provider’s Relationship to Dependent: __________________________________________________
TYPES: _____________________________________________________________________________
Total estimated value per month: __________________
11. Is your dependent receiving other benefits (WIC, Medicaid, Disability, Social Security, etc.), paid to them directly?
Please Provide Documentation.
___No ___Yes TYPES: _________________________________________________________________________
Total estimated value per month: ___________________
Certifications and Signatures
For office use only: Approved Rejected
Financial Aid Officer: Date:
I hereby certify that all information contained in this appeal, including the personal statement and documentation, is true and complete to the
best of my knowledge.
_________________________________________ ______________________________________
Student’s Signature Date
Warning: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail , or both.