2017-2018 Other Dependents Form (Independent Student)
Per your 2017-18 FAFSA application, you answered "YES" to "Do you have dependents (other than
your children or spouse) who live with you and who receive more than half of their support from you,
now and through June 30, 2018?” Please confirm these dependents meet the following other
dependent federal definition.
1. Do you support dependents other than your children or spouse as defined below?
YES → Select Yes if other people (not your children or spouse) live with you. These other
dependents must also be receiving more than half of their support from you and will continue to receive
more than half of their support from you between July 1, 2017 and June 30, 2018. Support includes
money, housing, food, clothes, medical and dental care, gifts, loans, payment of college costs, etc.
List
these other dependents on your 17-18 Independent Verification Worksheet in the table provided.
Complete steps 2-3, and sign signature section below.
NO → Select No if you do not have dependents (other than your children or spouse). Also select
No if you have dependents, but they are not receiving more than half of their support from you
between July 1, 2017 and June 30, 2018. Sign signature section below and return.
2. Prov
ide a support statement below from all adult other dependents if they now live with you, and you provide
more than half of their support and you will continue to provide more than half of their support between July 1,
2017 and June 30, 2018. If the other dependents were not employed and had no income earned from work in
2015, please have them include that in their support statement below. Attach a separate sheet if necessary.
3. Submit verification of the other dependent’s income. Please submit any one of the following for each adult
dependent: a copy of their 2015 W-2’s, 2015 tax return transcript, or unemployment benefits etc.
_____ → initial here if, you (other dependent) were not employed & had no income earned from work in 2015.
Certification and Signature: Each person signing below certifies
that all of the information reported is complete and correct.
WARNING: If you purposely give false or
misleading information, you may be
fined, sent to prison, or both.
Student Signature (Required) Date ”Other Dependent’s” Signature (Required, unless a minor) Date
We cannot process your financial aid until all required materials have been received.
Please return this completed form and all other required materials to:
Ottumwa Campus: IHCC Ottumwa Campus, Attn. Financial Aid, 525 Grandview Avenue, Ottumwa, Iowa 52501
Fax: 641-683-5741, P
hone: 800-726-2585, ext. 5262 or 641-683-5262 OneStop@indianhills.edu
