Verification of Dependents Other than a Spouse/Child 2012-2013

              FDEPV 07/27/2012
Rose State College
Office of Student Financial Aid and Scholarships
(405) 733-7424 Phone (405) 736-0359 Fax
Verification of Dependents Other than a Spouse/Child 2012-2013
Student Name: __________________________ Student ID# ____________
On your 2012-2013 Free Application for Federal Student Aid (FAFSA) you answered “Yes” to the question, “Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their support from you, now and through June 30, 2013?” Our office requires additional information to determine if this person qualifies as your dependent for federal financial aid purposes. Section 1 - Your Dependents Other than a Child or Spouse
In the chart below, list all people that you support ONLY if they:
● Currently live with you, AND
● Receive more than half of their financial support from you, AND
● Will continue to receive more than half of their financial support from you July 1, 2012 through June 30, 2013.
Full Name
Age
Relationship
College
Section 2 - Sources of Financial Support for Your Dependents Other than a Child or Spouse
Check all boxes below and on the back of this page for each type of Financial Support the person(s) listed in Section 1 receive. List the name of each person who receives it, and the monthly amount that person receives. (Financial Support may include earnings from work, Social Security Benefits, Unemployment Benefits, Support from You, Financial Aid, Child Support Received, Etc.)
Government Aid - Food Stamps, Financial Aid, Free or Reduced Price Lunch, Medicaid, Medicare, Military Benefits (Including Housing), Section 8, Special Supplemental Nutrition Program for Women, Infants & Children (WIC), Supplemental Security Income (SSI), Temporary Assistance for Needy Families (TANF):
________________________________________________________________________________________
FDEPV 07/27/2012
Unemployment (Provide the monthly amount for each person): _________________________________
________________________________________________________________________________________
Earnings from Work (Provide the monthly amount for each person): __________________________
______________________________________________________________________________________
Child Support Received (Provide the monthly amount for each person): ________________________
______________________________________________________________________________________
Worker’s Compensation (Provide the monthly amount for each person): ________________________
_______________________________________________________________________________________ Support from You (Provide the monthly amount for each person): _____________________________
_______________________________________________________________________________________
Other Income not Listed Above (Provide the monthly amount for each person):___________________
_______________________________________________________________________________________
Section 3 – Signature
By signing this form, I certify that all the information reported is complete and correct.
______________________________________________ _____________________
Student Date
Once this form is reviewed, additional documentation could be required. Final determination of your allowable household members and/or changes to your dependency status will be made after review of all information received. If your dependency status for federal financial aid changes from Independent to Dependent, you will be notified of further action needed.
WARNING: If you purposely give false or misleading information on this form, you may be fined, be sentenced to jail, or both.