Emancipated Student Form
PARENT OR GUARDIAN STATEMENT FOR A STUDENT CLAIMING EMANCIPATION
I (We)
,
the parent(s) or guardian(s) of
,
do entirely surrender the right to the care, custody, and earnings of
and I (we) have not supported or maintained said person since
Month
☐ Yes
Have you contributed to his or her support in any way?
Day
Year
☐ No
Nature and amount of support
I (We) have not claimed the above person as an income tax exemption for the last tax year, nor will I (we) for
subsequent years.
If this form is to be used as documentation, official IRS tax transcripts for the past two years for the
student’s parent(s) or guardian(s) should be included.
I (We) certify the information provided is accurate to the best of my (our) knowledge.
Signature(s) of parent(s) or guardian(s)
Subscribed and sworn to (or affirmed) before me this
Date
day of
, Year
My commission expires:
Notary Public
If you are claiming emancipated student status, you may be required to provide additional supportive
evidence. The Office of the Registrar will contact you if this is necessary.
NOTE: Residing in Wyoming primarily as a student will not support a claim for resident status for tuition
purposes, even if this form is properly completed and submitted.
Office of the Registrar January 2016 - 1