Financial Aid Office · 197 Franklin Street, Auburn NY 13021· FAX 315-252-2185

Auburn 315-255-1743 ext. 2470 · Fulton 315-592-4143 ext. 3004




Student Name ________________________________        Cayuga ID#  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 complete the following form.  Once you have entered the necessary information online, you will need to print the form, provide all required signatures and return it to the CCC Financial Aid Office.  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?   (Mark 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 2012?   (Mark one)                                          Yes                  No


If yes, who claimed you as a tax exemption in 2012?            Name:___________________   Relationship:____________


Who will claim you as a tax exemption in 2013?                    Name:___________________   Relationship:____________


Who claimed your dependent as an exemption in 2012?        Name:___________________  Relationship:____________


Who will claim your dependent as an exemption in 2013?    Name:___________________  Relationship:____________


Who provides medical insurance for you?                              Name:___________________  Relationship:____________


Who provides medical insurance for your dependent?           Name:___________________  Relationship:____________


What is the amount of child support received in 2012?                                 $___________________________


What is the estimated annual child support you will receive in 2013?          $___________________________


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 2012 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