· CAYUGA COMMUNITY COLLEGE ·
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
1-800-908-9946.