PURDUE
UNIVERSITY
®
NORTHWEST
Independent Status Verification Form 2021-2022
STUDENT NAME: _____________________________________DATE: _________________________
When completing the 2021-2022 Free Application for Federal Student Aid (FAFSA), you indicated you were independent
for financial aid purposes due to at least one of the reasons listed on this form. Check the item that applies to you and
submit the appropriate documentation with this form.
At any time since you turned age 13, were both parents deceased, were you in foster care, or a dependent or
ward of the court?
Documentation Required: Photocopies of parents’ death certificates, or photocopies of court documents
attesting to your foster care or ward-of-the-court status.
As determined by a court in your State of legal residence, are you or were you an emancipated minor?
Documentation Required: Photocopies of court documents attesting to your emancipated minor status.
As determined by a court in your State of legal residence, does someone other than your parent or stepparent
have legal guardianship of you?
Documentation Required: Photocopies of court documents appointing your legal guardian.
At any time on or after July 1, 2020, did your high school or school district homeless liaison determine that
you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?
Documentation Required: A photocopy of a signed letter on official letterhead from your school district
certifying your homeless or at risk status.
At any time on or after July 1, 2020, did the director of an emergency shelter or transitional housing
program funded by the U.S. Department of Housing and Urban Development determine that you were an
unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?
Documentation Required: A photocopy of a signed letter on official letterhead from a director of a
qualifying shelter or program certifying your homeless or at risk status.
At any time on or after July 1, 2020, did the director of a runaway or homeless youth center or transitional
living program determine that you were an unaccompanied youth who was homeless or were self-supporting
and at risk of being homeless?
Documentation Required: A photocopy of a signed letter on official letterhead from a director of a
qualifying shelter or program certifying your homeless or at risk status.
I do not qualify as an Independent Student for Financial Aid purposes.
Please be aware that if you cannot provide the documentation outlined on this form, you are likely to be
considered dependent for financial aid purposes. Upon review of this form and the documentation submitted, your
financial aid file will be reviewed and you will be notified if it is determined that you need to make corrections to
your 2021-2022 FAFSA.
Statement of Certification:
I certify that the information provided on this form and any attachments are true and correct.
Student Signature: ________________________ PUID____________________ Date: _________________
Office Use Only – RRAAREQ:______NSIS22 (R)
2200 169
th
Street Hammond, IN 46323
(219) 989-2301 fax (219) 989-2141
1401 S. U.S. Hwy. 421 Westville, IN 46391
(219) 785-5460 fax (219) 785-5653
