SUPPDEP16
2016-2017 Documentation of Dependent Support
You indicated on the 2016-2017 FAFSA application that you will provide more than 50% of the support for at least one child OR that you have a
legal dependent (other than a spouse) who lives with you and for whom you will provide more than 50% of the support for from July 1, 2016
through June 30, 2017. A student who reports supporting a child or other legal dependent must submit documentation of sufficient
income/resources to support themselves and provide more than 50% of the support for the child/legal dependent. You must complete and
return this document in order for your financial aid eligibility to be determined. You may be asked to provide additional supporting
documentation.
Student Last Name
First Name
Middle I.
Student NCC ID# or Social Security #
Section A: Your Dependents
List below all dependent children or dependents (other than a spouse) for whom you will provide more than 50% support
from July 1, 2016 through June 30, 2017:
______________________________
__________________
______________________________
__________________
Dependent Name
Age/Relationship to you
Dependent Name
Age/Relationship to you
______________________________
__________________
______________________________
__________________
Dependent Name
Age/Relationship to you
Dependent Name
Age/Relationship to you
Section B: Your Residence
Do you live with your parents?
Yes
No
(If the student is living with a parent who is paying for most of the household expenses, the parent would usually be considered the primary source of
support to the student and student’s dependent, and the student would answer “No” to the FAFSA questions about supporting children or legal
dependents.)
Do you live with someone other than your parents? Yes
If yes, with whom do you live?
No
______________________________________
Name
Do you live alone with your dependent child or other dependent?
If yes, when did you establish residence on your own?
Yes
_____________________________________
Relationship to you
No
_____________/_____________
Month
Year
Section C: Monthly Support You Provide
List the monthly expenses you pay. If you are living with your parents or someone other than a parent, but are paying for you
and your dependent’s housing expenses (e.g., rent, food, utilities), please complete the following and attach supporting
documentation. (Documentation can include a letter from parent/person to whom you pay rent, copies of monthly utility bills, etc.)
List the monthly housing expenses that you pay:
List the monthly child care expenses that you pay:
List other monthly expenses that you pay:
__________________________
__________________________
__________________________
Amount Paid Monthly
$__________________
$__________________
$__________________
$__________________
$__________________
*** Complete Reverse Side of Form ***
2016-2017 Documentation of Dependent Support
To Whom:
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________
Section D: Sources of Income/Additional Resources
Indicate below each type and amount of monthly income/resources you are currently receiving that should be considered in
determining whether you are providing more than 50% of the support for a dependent. You may be required to provide additional
documentation.
Monthly income from work
Monthly Unemployment
Monthly Child Support Received
Monthly Worker’s Compensation
$___________________________per month
$___________________________per month
$___________________________per month
$___________________________per month
Government Aid -list monthly amounts and type of assistance
(Include, SNAP/Food Stamp Assistance, Cash Assistance, Medicare, Military Benefits including housing allowance, Section 8, WIC, Social Security, etc.)
Type of assistance:____________________________________
Type of assistance:____________________________________
Type of assistance:____________________________________
Type of assistance:____________________________________
$_______________________per month
$_______________________per month
$_______________________per month
$_______________________per month
Monthly money received, or paid on your behalf (e.g. bills, groceries) – list type of monthly expense paid and who pays it
Type of Expense:__________________Paid by whom__________________
$___________________per month
Type of Expense:__________________Paid by whom__________________
$___________________per month
Type of Expense:__________________Paid by whom__________________
$___________________per month
Section E: Describe the living circumstances of you and your dependent(s):
(Provide any additional information that should be considered in documenting your support of yourself and your dependent(s):
Once this form has been reviewed, additional documentation may be required. Final determination of your dependency status will be made
after review of all information received. You will be notified in writing of the outcome of this review. If you have any questions about the
requested information please contact the NCC Financial Aid Office at 610-861-5510.
F: Student Signature – By signing this form, I certify that all reported information is complete and correct.
Student Signature
Date
Return completed form to:
Financial Aid Office
Northampton Community College
3835 Green Pond Road
Bethlehem, PA 18020-7599
By Fax: 610-861-4565