Student’s Name _______________________________ Student’s ID Number _____________
Student must initial ________ _______ Page 3 of 3
Revised January 2020
Does your dependent(s) work or receive an income? Yes No
Total monthly income for your dependent(s). _______________________________________________
Income Sources (i.e. work, SSI, child support, government benefits, etc.) List all.
*** You must provide documentation of any income listed for your dependent(s), such as a signed copy
of recent federal tax return, tax return transcript from IRS, W2s, monthly pay stubs, government benefit
verifications from government offices, proof of child support received, etc. If your dependent has no
income, a signed statement indicating not employed and not required to file taxes.
Were your dependents claimed by anyone other than you on the 2018 tax return? Yes No
If Yes, please provide name and relation to dependent. ________________________________________
By signing this form, I verify that I will be supporting the person(s) listed above, even though we are not
in a legal binding relationship, providing more than 50% of their financial support from now through June
Signing below certifies that all of the
information reported is complete and correct.
The student whose information was
reported on the FAFSA must sign and date.
Student’s Signature Date
Do not mail this worksheet to the U.S. Department of Education
Submit this worksheet to
Edison State Community College
Office of Student Financial Aid
1973 Edison Dr. Piqua, OH 45356
CERTIFICATIONS AND SIGNATURES – Must Complete
WARNING: If you purposely give false or
misleading information on this worksheet, you
may be fined, sent to prison, or both.
click to sign
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