PROOF OF DEPENDENT FORM
(2020-2021 Academic Year)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 email@example.com
FA-404-PRFDEP 2021 20200416
On the FAFSA you indicated you have a child or dependent whom you provide at least half of their support.
Do you have a child or children?
If Yes, you must attach a copy of your child(ren)’s birth certificate showing you as the parent.
If yes, you must attach a doctor’s statement confirming pregnancy and your due date
occurring prior to 6/30/2021
Will your child(ren) receive more than half
of their support from you between July 1,
2020 and June 30, 2021?
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 between July 1, 2020
June 30, 2021?
Yes No If yes, please list their names and relationship to you:
Will you receive money from any of the following between 7/1/2020– 6/30/2021?
Financial aid and/or scholarships?
Women, Infants and Children (WIC) Assistance?
Social Security Benefits?
Housing Assistance / Benefits (including Section 8 / low income housing)?
Medical Assistance (AHCCCS)
Supplemental Security Income (SSI)?
Welfare (including TANF)?
(Unemployment, Disability, etc.)
I certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving false or misleading
information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent to prison or both. I hereby
provide consent for the use of electronic records and signatures on all financial aid documents. I understand that if I choose to sign
electronically, my electronic signature constitutes a binding contract and may not be denied legal effect, validity, or enforceability solely
because it is in electronic form or because an electronic signature or electronic record was used in its formation.
Student's Signature and Date How do I create a digital signature with Adobe?
CCC ID# Last Name First Name MI
Mailing Address City ST Zip Code
Telephone No. (include area code) Email Address
click to sign
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