(GRAY) 15-16 Proof of Dependents Form
Financial Aid Office P.O. Box 804 Spindale, NC 28160
Proof of Dependent(s) Form
Student Name ________________________ Student ID #: __________________ SSN xxx-xx- __________
Please list the names and ages of YOUR dependents and their relationship to you. Please note that you may be
asked to provide further documentation (e.g., Birth Certificate, Legal Guardianship, tax return, etc.).
Dependents are those people that you will support between July 1, 2015 and June 30, 2016. Include your children if they
receive MORE THAN HALF of their support from you. Include other people only if they meet the following criteria:
1. they now live with you, and
2. they now receive more than half of their support from you, and
3. they will continue to receive this support from you through June 2016.
Support includes money, housing, food, clothes, car, medical and dental care, payment of college costs, and similar expenses
paid by you (Student). If someone is providing this support for you, then you will not be able to claim a dependent on your
FAFSA. You may be asked to provide documentation to substantiate your claim of support for the person(s) listed below as
Name Age Relationship
1. ________________________ _____ _____________________________________
2. ________________________ _____ _____________________________________
3. __________________________ _____ _____________________________________
Where are the dependent(s) named above currently living?
If “other” is checked, please explain:
You (the student) lives:
with your parent(s) with a friend in my own house, apt, condo, etc. other
If “other” is checked, please explain:
If the dependent(s) is someone other than your children or spouse (eg. Grandparent, Niece, Brother, etc), do they
receive any income assistance (i.e. social security benefits, retirement, welfare, etc)?
If yes, please list all types and total amount received.
Benefit Type(s): _____________________________________________ Monthly Amount: $ ______________
(GRAY) 15-16 Proof of Dependents Form
Did your dependent file a 2014 tax return?
If yes, please provide a copy of their 2014 tax return and W-2’s.
Were you (the student) claimed by your parent(s) on their tax return for the previous year?
Was your dependent claimed by anyone other than you (the student) on the 2014 tax return?
If yes, please list the name of the person and their relationship to you:
Are you currently working? Yes No If yes, what are your earnings? $ _________ per month
Did you/will you file a 2014 Federal Tax Return
(1040, 1040A, or 1040EZ)
? Yes No
If no, list the name of your employer(s) and your yearly income from that/those employer(s) for 2014.
Employer: ____________________________________ Amount Earned: $ ____________
Employer: ____________________________________ Amount Earned: $ ____________
A W-2 will need to be provided if you had earnings that were not reported on a tax return.
Verification of Benefits (Student)
Type of Benefits
Amount Per Month
Social Security Income
Food Stamps (SNAP)
Temporary Assistance for
Needy Families (TANF)
Child Support Received
Do you receive WIC?
Yes No
I certify that the information provided is true and correct. Furthermore, I agree to provide copies of my US Federal Income
Tax Return(s) and/or W-2’s if requested. I understand that if I purposely give false or misleading information in connection
with my application for Federal Aid, I may be subject to a fine up to $20,000, sent to prison, or both. I also understand that
the information provided on this form may be used to override federal regulations regarding my dependency status. I
understand that if I move back in with my parent(s) or receive any kind of support from them, I must report this to the
Financial Aid Office immediately.
__________________________________________________ __________________
Student’s Signature Date