__________________________
2018-2019
Verification of Support of Dependents
Student ID________________________________________
_________________________________________________ _______________________________________
Last Name First Name
According to federal regulations “dependents” are children or other persons who live in your home (a residence you own or
rent) and receive more than 50% of their living expenses and other financial support from you between July 1, 2018 and June
30, 2019. We are unable to determine if the dependent(s) included on your FAFSA CA Dream Application (if AB540 or AB2000) or
other documents submitted to the Office of Financial Aid meet this definition. Complete the form by listing the qualified
dependent(s) included in the number in household on your application.
No ____
No____
Name of dependent(s): _____________________________________________ Age of dependent(s): _______________
Current address of dependent(s): ______________________________________________________________________
Street, City, State ___________________________________________________________________________________
When did the dependent(s) begin living at this address? _____________
Are you (or parents, if dependent) legally responsible for the rent/mortgage payments at this address? Yes_____
Will the dependent(s) continue to live at this address until June 30, 2019? Yes_____
Relationship of dependent(s) to the student:
_____Mot
her _____Father _____Child __
___Sister _____Brother _____Aunt/Uncle _____Cousin
_____Niece/Nephew _____Grandparent _____ Other:
___________________
Report all
income sources received by the dependent(s). Do not leave any income source blank. If the dependent(s) does not
receive income from the listed source, put a "0". If someone receives income for the dependent(s), check the "Yes" box and indicate
the relationship of that person to the dependent(s) (i.e. mother, father).
Welfare (TANF / Cal Works) Amount received per month: $ ___________ Yes_____ No_____
Social Security / CAPI Amount received per month: $ ___________ Yes_____ No_____
General Relief / Refugee Cash Assistance Amount received per month: $ ___________ Yes_____ No_____
Child Support received from another parent Amount received per month: $ ___________ Yes_____ No_____
Income from Work / Unemployment Amount received per month: $ ___________ Yes_____ No_____
Amount of support received from Friends and Relatives per month: $ ___________ Yes_____ No_____
Financial Aid (grants, loans, & scholarships) Amount received per YEAR: $ ___________ Yes_____ No_____
Other (please specify): _________________ Amount received per month: $ ___________ Yes_____ No_____
(Further documentation may be requested when form is submitted)
CERTIFICATION: I certify that all information on this form is true, complete, and accurate. Upon request, I agree to provide proof of the information reported on this
form. False statements or misrepresentation can cause a denial, reduction, withdrawal, and/or repayment of financial aid. I give permission to the Office of Financial
Aid to make corrections/adjustments to data on my FAFSA based on forms and/or documents submitted.
_________________________________________________________
Student Signature
Date
1570 East Colorado Blvd.L-114, Pasadena, California 91106
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2003
19DPSP
