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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 _________________________
City _________________________
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:
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.
2. Where do the dependent(s) named above live?
[ ] With the student
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)
If Other is checked, please explain:
5. Were you (the student) claimed by your parent(s) on their previous
year tax return?
[ ] Yes
6. Was your dependent claimed by anyone other than you (the student)
on the previous year tax return?
[ ] No
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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