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Proof of Dependent(s) Form

This form is used to gather information from unmarried students who are under 24 years old and claim to have dependents.

Please answer ALL questions carefully and attach supporting documentation. DO NOT LEAVE ANY BLANKS. Please print your answers.

Name _________________________
Social Security Number ___________
Address _____________________________________________

City _________________________
State ____________________________
Zip Code _________________________

1. Please list the names and ages of YOUR dependents and their relationship to you. You must attach legal documentation of their relationship (e.g., Birth Certificate, Legal Guardianship, etc.).

Dependents are those people that you will support between July 1, 1996 and June 30, 1997. Include your children if they get MORE THAN HALF of their support from you. Include other people only if they meet the following criteria:

1. they now live with you, and
2. they now get more than half their support from you, and
3. they will continue to get this support from you between July 1, 1996 and June 30, 1997.

Support includes money, housing, food, clothes, car, medical and dental care, payment of college costs, and similar expenses. You must provide documentation such as receipts to substantiate your claim of support for the persons listed below as dependents.

Name Age Relationship
_____________________________ _______ _______________________
_____________________________ _______ _______________________
_____________________________ _______ _______________________

2. Where do the dependent(s) named above live?

[ ] With the student
[ ] With the student's parent(s)
[ ] Other

If Other is checked, please explain:

3. What child care provisions have you made for while you're in class?

4. You (the student) will live:

[ ] With your parent(s)
[ ] Other

If Other is checked, please explain:

5. Were you (the student) claimed by your parent(s) on their previous year tax return?

[ ] Yes
[ ] No

6. Was your dependent claimed by anyone other than you (the student) on the previous year tax return?

[ ] No
[ ] Yes

If yes, please list the name of that person and their relationship to you, the student.

Name: _______________________________________

Relationship: _______________________________________

7. Please list the estimated monthly expense for the support of your dependent(s), over and above the support received through any federal programs listed below.

$__________ per month for

8. Please list all source(s) of support. You must attach supporting documents. (Examples include: copy of most recent check stub; AFDC check; Notice of Action form from your worker with current date; cancelled checks or other proof of child support paid; WIC program eligibility notice; Medi-Cal eligibility notice for dependent).

 

 
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