Financial Aid Office ·
Auburn 315-255-1743 ext. 2470 ·
Student
Name ________________________________ Social
Security #: ______________________
Banner ID Number
C
On your financial aid application you indicated that you have children or other dependents that live with you and receive more than half of their support from you. Since this statement is the basis for your independent status it is necessary for you to validate your response. Please answer the following questions. Additional information may be requested.
What is the name, birth date and relationship of your dependent?
Name:___________________________ Birth Date:__________ Relationship:_______________
Does the dependent live with you? (Circle one) Yes No
If yes, list the name and relationship of other members of the household where you live:
Name: ___________________________________ Relationship: ____________________
Name: ___________________________________ Relationship: ____________________
Did you file taxes for 2011? (Circle one) Yes No
If yes, who claimed you as a tax exemption in 2011? ________________________________
Who do you expect to claim you as a tax exemption in 2012? ________________________________
Who claimed your dependent as an exemption in 2011? ________________________________
Who provides medical insurance for you? ________________________________
Who provides medical insurance for your dependent? ________________________________
What is the amount of child support received in 2011? ________________________________
What is the estimated annual child support you will receive in 2012? __________________________
Please list other sources of income you receive to help support you
and your dependent(s), example – food stamps, public assistance, etc. __________________________
__________________________________________________ _____________________
Student Signature Date
Please return this form
along with a 2011 IRS tax transcript to
the Financial Aid office at Cayuga Community College. You can obtain a tax transcript at www.irs.gov or by calling 1-800-908-9946.