YubaCommunityCollegeDistrict
F
inancial
A
id
O
ffices
20202021DependentSupportVerification
Thereisadiscrepancywiththedependent(s)and/orincomeyoureportedonyour20202021FAFSAorVerificationWorksheet
thatneedstoberesolvedbeforetheFinancialAidOfficecandetermineyoureligibilityforfinancialaid.Pleasecompleteand
returnthisformtotheFinancialAidOfficeatyourcampus.
Pleaseanswerallquestions.Donotleaveanyitemsblank.Ifanitemdoes notapply,enter N/Aor$0intheareawhere an
amountisrequested.SubmitthisformwithsupportingdocumentationtotheFinancialAidOffice.
Note:Ifyouareunabletomeettheminimumsupportrequirements
setforthbyYCCDandFederalRegulationsandyouare
undertheageof24,youwillberequiredtoaddyourparent’sinformationtoyourexistingFAFSAapplication.
STUDENTINFORMATION
_____________________________________________________ __________________________________
LastName  FirstStudentID
_________________________________________________________
__________________________________
MailingAddress(includeapt.no.)PhoneNumber(IncludeAreaCode)

_________________________________________________________
City State ZipCode
A.INDIVIDUALWHOMISCOMPLETINGTHISFORM:
IndependentStudent:Thatfinanciallysupportsadependentmorethan50%
DependentStudent’sParent:Thatfinanciallysupportsadependentotherthanachildmorethan50%
B.DEPENDENTINFORMATION
CHECKTHEBOXTHATAPPLIESTOYOU SUBMITTHEFOLLOWINGDOCUMENTATION
IDONOThaveadependentforwhomIprovidemorethan50%
oftheirfinancialsupport.
Noadditionaldocumentationrequired.
IDOhaveadependentforwhichIprovidemorethan50%of
theirfinancialsupport.
CompletetheProofofDependentSupportform
Provideproofofincomeearnedorbenefits
received
fromJuly1,2020toJune30,2021.
Dependentsare:
Yourchildrenifyouwillprovidemorethan50%oftheirsupportfromJuly1,2020throughJune30,2021,eveniftheydonot
livewithyou.
Otherdependentsiftheynowlivewithyou,andyouprovidemorethan50%oftheirsupportandwillcontinueto
providemore
than50%oftheirsupportthroughJune30,2021.
COMPLETEALLITEMSFOR
EACHDEPENDENT
DEPENDENT1 DEPENDENT2
NameofDependent
DateofBirth

Relationship

Page1DependentSupportVerification
YubaCollege
2088NorthBealeRoad
Marysville,CA95901
5307497999
WoodlandCommunityCollege
2300EastGibsonRoad
Woodland,CA95776
5306615725
LakeCounty Campus
15880DamRoadExtension
Clearlake,CA95422
7079957923
C.HOUSEHOLDINFORMATION
COMPLETEALLITEMSFOR
EACHDEPENDENT
DEPENDENT1 DEPENDENT2
Wheredoesthedependentlive?
Ifother,listthe:
1.Nameofthepersonwhotheylivewith.
2.Theirrelationshiptothedependent.
3.Howlongtheyhavelivedwiththe
otherperson.
WiththestudentOther

Withthestudent’sparent
WiththestudentOther

Withthestudent’sparent

D.ADDITIONALHOUSEHOLDINFORMATION
1.Enterthetotalnumberofpeoplewholiveinyourhousehold:_____________________
2.Enterthetotalnumberofpeoplewholiveinyourhouseholdthatyoufinanciallysupport._____________________
3.Howlonghasthedependentlivedwithyou?
Dependent1___________________________________Dependent2___________________________________
4.HowmanymonthswillthedependentliveinyourhouseholdfromJuly1,2020toJune30,2021?
Dependent1___________________________________Dependent2___________________________________
E.INCOME
COMPLETEALLITEMSFOR
EACHDEPENDENT
DEPENDENT1 DEPENDENT2
Wasthedependentclaimedonyour2019
FederalTaxReturn?Ifno,listthe:
1.Nameofthepersonwhoclaimedthem.
2.Person’srelationshiptothedependent.
Yes No Yes No


INCOMEINFORMATIONFORSTUDENTORPARENT
Pleaseanswerthefollowingquestions:
CheckOne
Provideproofofincomeearnedorbenefitsreceived
fromJuly1,2020toJune30,2021.Submitthe
followingdocumentation:
Areyoucurrentlyworking? YesNo RecentpaycheckstubwithYTDtotal
Doyoureceivechildsupport? YesNo CourtDocument/BankStatements/CopyofChecks
DoyoureceiveSocialSecurityBenefits? YesNo SocialSecurityStatement:Type____________________
DoyoureceiveTANF,CalWorks,orTribalTANF? YesNo NoticeofAction/PassporttoServices
DoyoureceiveSNAP,CalFresh,orfoodstamps? YesNo Statementfromagencythatissuedthebenefits
DoyoureceiveWICbenefits? YesNo Statementfromagencythatissuedthebenefits
Doyoureceiveanyothertypeofincome? YesNo Proofofincome/benefitstudentorparentisreceiving
Doyoureceivesupportfromanyoneelse? YesNo Proofofsupportstudentorparentisreceiving
INCOMEINFORMATIONFORDEPENDENTYOUSUPPORT
Doesthedependentyousupporthaveincome? YesNo Proofofincome/benefits
Doesthedependentyousupportreceiveany
financialsupportfromothersources?
YesNo
Proofofsupportfromagencyorindividualthat
providedthesupport
Doesthedependentyousupportcontribute
towardsthecostofhouseholdexpenses?
YesNo
Howmuchdotheycontributepermonth?
$_______________________
Page2DependentSupportVerification
F.HOUSEHOLDEXPENSES
G.DEPENDENTEXPENSES
H.SUPPORTEVALUATION
ThisinformationwillbeusedbytheFinancialAidOfficetodeterminewhetheryouprovidemorethanhalfofthesupportfor
thedependentsyouhavelisted.
I.CERTIFICATION
Icertifythattheinformationprovidedonthisformandanyattachmentsistrueandcorrecttothebestofmyknowledge.Iunderstand
thatfalseormisleadinginformationmaybecausefordenial,termination,and/orrepaymentoffinancialaidfunds.
_______________________________________________________ _______________________________________________________
StudentSignatureDate ParentSignature  Date
FORFINANCIALAIDOFFICEUSEONLY
SupportTestWorksheetCompletedDateCompleted:__________________________
Approved:MeetssupporttestDateAwarded:__________________________ISIR:____________EFC:__________________
Denied:Doesnotmeetsupporttest Studentconsidered“dependent”andmustprovideparent(s)informationontheirFAFSA.
Comments:____________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
_______________________________________________________ 
FAStaffSignatureDate 
Page3DependentSupportVerification
Rev.9/27/19
ProvideExpensesfor
EntireHousehold:
CurrentMonthly
Expense
AmountYouPay
PerMonth
AmountSomeone
ElsePays
NameifSomeoneElsePays
Rent/Mortgage

Utilities(Water,Electricity,
Gas,Trash)

OtherExpenses(Phone/Cell,
Cable,Internet)

Food

Transportation(carpayment,
gas,autoinsurance)

TotalMonthlyExpenses

Provideexpensesfor
Dependent:
CurrentMonthly
Expense
AmountYouPay
PerMonth
AmountSomeone
ElsePays
NameifSomeoneElsePays
Childcare

ClothingandotherPersonal
Expenses

Other:__________________

TotalMonthlyExpenses

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