Dr. H.A. Miller Student Services Center
417 Schepps Blvd., Clovis, NM 88101
Ph. (575) 769-4060 * Fax (575) 769-4027
You included an individual on your financial aid application who needs to meet the following requirements to be included
as part of the household for financial aid purposes. You must complete one form per person being supported.
They must currently be living with you.
You and/or your parents must provide more than half of their support and will continue to provide more than half of
their support from July 1, 2020 to June 30, 2021
If the person you listed is a minor, proof of legal guardianship is required. A state or district judge must have
appointed you as a legal guardian for this person. Notarized letters are not considered proof of legal documents.
You must complete the worksheet below, providing accurate dollar amounts and supporting documentation for the person you are
supporting, otherwise this worksheet will be DISAPPROVED.
Print the name and social security number of the person providing the support
Provide the following information for the person being supported
Age: Relationship to Provider:
Does this person live with you? Yes No How long has this person lived with you?
Who owns the home or pays rent? Amount paid monthly $
Who pays the utility bills for this residence? Amount paid monthly $
Does this person work? Yes No If yes, amount earned per month $
Does this person pay any of his/her expenses? Yes No If yes, please provide receipts and list expenses.
Does this person receive any other income in their name or on their behalf per month (Cash, Social Security, Supplemental Income,
Retirement Pensions, VA Benefits, Alimony, Child Support, Workers Compensation, TANF/WIC, Food Stamps, Savings, or Other)?
Type of Income Amount per Month
Please complete back page