Fillable Students who are unmarried and under 24 years (Edison State Community College)

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Students who are unmarried and under 24 years (Edison State Community College)

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Student’s Name _______________________________ Student’s ID Number _____________
Student must initial ________ _______ Page 1 of 3
Revised January 2020
Students who are unmarried and under 24 years of age but reported on their FAFSA that they have
dependents other than a spouse and children must prove that they provide more than 50% of the financial
support for those dependents in order to be classified as an Independent Student.
Please answer ALL of the following questions carefully and attach requested documentation to support
your claim. Forms submitted without proper documentation will be considered incomplete until
documentation has been received.
Dependents are people who you will financially support between July 1, 2020, and June 30, 2021, that
live with you.
Support includes money, housing, food, clothes, car expenses, medical and dental care, child care costs,
and any other similar expenses or bills you pay on their behalf.
*** IMPORTANT ***
If you are unable to prove you provide 50% of the financial support for the dependents you claim, you
will be considered a DEPENDENT student. You will be required to submit a correction to your FAFSA
to include parental information, income and signature.
Financial aid eligibility will not be determined or awarded until the FAFSA correction is received.
\
Section 1 - Student Information
____________________________________________ ____________________________
Student’s Last Name First Name M.I. Student’s Social Security Number
_____________________________________________ ____________________________
Student’s Street Address (include apt. no.) Student’s Date of Birth
_____________________________________________ ____________________________
City State Zip Code Student’s Email Address
_____________________________________________ ____________________________
Student’s Home Phone Number (include area code) Student’s Alternate or Cell Phone Number
STUDENT INFORMATION – MUST COMPLETE
2020-2021 Proof of Dependent(s)
Financial Support
For Dependents OTHER THAN Spouse/Children
Student’s Name _______________________________ Student’s ID Number _____________
Student must initial ________ _______ Page 2 of 3
Revised January 2020
Do you (the student) work or receive an income? Yes No
Total monthly income for you. _________________________________________________________
Income Sources (i.e. work, SSI, child support, government benefits, etc.) List all.
____________________________________________________________________________________
____________________________________________________________________________________
*** You must provide documentation of any income listed, 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 no, signed statement indicating you were not
employed and not required to file taxes.
Were you (the student) claimed on your parent(s) 2018 tax return? Yes No
Do you live with your parents or another family member? Yes No
Please list all expenses, average monthly amount, and indicated whether paid by you or your dependent.
Expense Item
Monthly Amount
Paid by
Student
Paid by
Dependent
Rent/mortgage
Utilities-gas, electric, water, sewer
Phone
Cable/internet
Transportation expenses
Medical/dental care
Child care
Clothing/personal
Other:
Other:
Total Monthly Expenses
Please list below the names and ages of the person(s) you are claiming as dependents on your 2020-2021
FAFSA who live with you.
Full Name
Age
Relationship
DEPENDENT INFORMATION – MUST COMPLETE
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
30, 2021.
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
WARNING: If you purposely give false or
misleading information on this worksheet, you
may be fined, sent to prison, or both.
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Students who are unmarried and under 24 years (Edison State Community College)

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Completed 26 July 2020

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