Indicate below the name of the person who paid the child support in the 2017 tax year, the name of the person to whom the
child support was paid, and the name(s) and age(s) of the child(ren) for whom child support was paid. Also include the total
annual dollar amount of child support that was paid for each child.
If more space is needed, provide a separate page that includes the student’s name and ID number at the top.
Name of Person
Who Paid Child
Name of Person to
Whom Child Support
was Paid
Name of Child for Whom
Support Was Paid
Age of
Total Amount of
Child Support Paid
in 2017
Note: If we have reason to believe that the information regarding child support paid is not accurate, we may require
additional documentation, such as:
A copy of the separation agreement or divorce decree that shows the amount of child support to be provided;
Copies of the child support payment checks or money order receipts.
Certification and Signature
Each person signing below certifies that all of the
information reported is complete and correct.
________________________________________ ________________________
Print Student’s Name Student’s ID Number
________________________________________ ________________________
Student’s Signature (Required) Date
________________________________________ ________________________
Parent’s Signature (dependent students only) Date
Return this form to:
Financial Aid Office, Southwestern Michigan College
58900 Cherry Grove Road, Dowagiac, MI 49047
or fax to 269-783-2114
Please note that submission of this form electronically should be encrypted to protect any personal or
confidential information.
Southwestern Michigan College
Verification of 2017 Child Support Paid
Financial Aid Office, 58900 Cherry Grove Road, Dowagiac, MI 49047
Phone: 269.783.2143 Fax 269.783.2114 Email:
WARNING: If you purposely give false or
misleading information you may be fined,
be sentenced to jail, or both.
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