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.
