2018-2019 Dependency Override - epcc.edu

1 First Name: _____ Last Name: _____ EPCC ID: _____ "The El Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran sexual orientation, or gender identity status, " 1 Rev. 03/05/ 2018 2018 -2019 Financial Aid Office Request for Dependency Override A Dependency Override constitutes any unusual circumstances forcing a dependent student to become an independent student. Complete this form and provide all the documentation requested. Submission of this appeal and documentation does not necessarily mean the petition will be approved each determination is made on a case by case basis. The Financial Aid Office decision is final and cannot be appealed to the Department of Education.

2 Unusual circumstances constitute: Unique or unusual family circumstances include family abuse or neglect. Parental desertion and other situations where contact between the student and parent is non-existent. The Financial Aid Office has the authority to determine what circumstances cannot be considered unusual. REQUIRED DOCUMENTS Student Statement A letter explaining in detailing the exceptional circumstances making you independent due to your current relationship with your parents. The letter must specify when you last had contact with them, why you cannot obtain information and support from them. Finally, state how you have been supporting yourself. Supporting Documentation Provide supporting documentation attesting to the circumstances described in your statement. Additional documentation may be required. Notarized Statements Two different notarized statements from professionals aware of your circumstances such as teachers, counselor, clergy, social worker, etc.

3 (Refer to page 4 and 5.) Benefits Statement Letter from Health and Human Services Commission if you are receiving Food Stamps/SNAP benefits. Tax Forms 2016 & 2017 IRS Tax Transcripts if you are required to file. 2016 & 2017 Non-filer Letters if you are not required to file. Financial Aid Form Complete the 2018 -2019 Institutional Verification Form, found at: First Name: _____ Last Name: _____ EPCC ID: _____ "The El Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran sexual orientation, or gender identity status, " 2 Rev. 03/05/ 2018 Dependency Override Please answer the following, if additional space is needed attach a separate sheet. 1. Did you live with either parent during 2017?

4 No Yes What was the last day that you lived with them? _____/_____/_____ 2. Do you receive or have you received financial support from your parents in the past year (such as monetary gifts, payments of bills, cash for expenses, etc.)? No Yes Indicate the amount and type of support for 2017 _____ When did you stop receiving support? _____/_____/_____ 3. Did your parents file a 2017 Federal Tax Return? No Yes Provide 2016 & 2017 IRS Tax Transcripts or attach a separate page stating the reason you cannot. 4. Did you file a 2017 Federal Tax Return? Yes No Why not? _____ 5. Did anyone besides yourself claim you as a TAX EXEMPTION on their 2017 Federal Tax Return? No Yes Provide their 2017 IRS Tax Transcripts. 6. My current permanent address is: _____ 7. I have lived at this address since: _____/_____/_____ 8. This property is owned by: _____ 9.

5 Is the residence listed above owned by a relative? No Yes How are you related? _____ First Name: _____ Last Name: _____ EPCC ID: _____ "The El Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran sexual orientation, or gender identity status, " 3 Rev. 03/05/ 2018 INCOME AND EXPENSES CERTIFICATION All of the information on this form is true and complete to the best of my knowledge. I understand that if all the information requested above is not supplied, no action will be taken on this request. If asked by an authorized official, I agree to give proof of the information I have provided on this form. I realize this proof must include IRS Tax Transcripts. I also realize if I do not provide proof when asked, I may not be processed for financial aid.

6 I also understand any suspected fraud will be reported to the proper authorities and the Office of Inspector General. Such things as falsified or counterfeit documents, irregular signatures, and certifications, false or fictitious names, addresses, staff, unreported or misreported receipt of student aid. No student or prospective student will be excluded from participation in or be denied the benefits of financial aid on the basis of race, color, age, national origin, religion, or sex. WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. _____ _____ Student Signature Date 2018 EXPECTED INCOME Estimated 2018 Taxable Income (wages, interest income, etc.) Yearly Amount *Income from Work $ *Other Taxable Income $ *Unemployment Benefits $ Estimated 2018 Untaxed Income and Benefits *Social Security Benefits $ *Aid to Families with Dependent Children (AFDC or ADC $ *Other Untaxed Income and Benefits (child support, etc.))

7 $ TOTAL YEARLY INCOME $ MONTHLY EXPENSES Monthly Amount Source of Income Housing $ Utilities $ Food $ Transportation (Gas and car maintenance) $ Car Payment $ TOTAL MONTHLY EXPENSES $ First Name: _____ Last Name: _____ EPCC ID: _____ "The El Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran sexual orientation, or gender identity status, " 4 Rev. 03/05/ 2018 REFERENCE 1. How long have you known the student? _____ 2. Are you related to the student? No Yes, how? _____ 3. With whom does the student reside? _____ 4. To the best of your knowledge has anyone claimed the student as an income tax exemption for the following years: 2016 Do not know No Yes, by whom_____ 2017 Do not know No Yes, by whom_____ 5.

8 Please explain briefly what you know to be the student s situation and if you are providing support of any kind. If you should need more space to explain, please attach a letter. _____ _____ _____ _____ _____ I certify that all of the information on this form is true and completed to the best of my knowledge. I also understand that I may be contacted if further information is needed. _____ _____ Name of Reference (please print) Official Title or Relationship to Student _____ _____ Signature Telephone Number _____ _____ Street Address, Box, Etc. Best Time to be Reached _____ _____ City, State, and Zip Date ACKNOWLEDGMENT STATE OF _____) ) COUNTY OF _____) On this _____day of _____20_____, before me, the undersigned Notary Public, personally appeared _____ to me known to be the individuals(s) described in and who executed the foregoing instrument, and acknowledged that he (she) (they) executed the same as his (her) (their) free act and deed.

9 My Commission expires _____ _____ Notary Public First Name: _____ Last Name: _____ EPCC ID: _____ "The El Paso County Community College District does not discriminate on the basis of race, color, national origin, religion, gender, age, disability, veteran sexual orientation, or gender identity status, " 5 Rev. 03/05/ 2018 REFERENCE 1. How long have you known the student? _____ 2. Are you related to the student? No Yes, how? _____ 3. With whom does the student reside? _____ 4. To the best of your knowledge has anyone claimed the student as an income tax exemption for the following years: 2016 Do not know No Yes, by whom_____ 2017 Do not know No Yes, by whom_____ 5.

10 Please explain briefly what you know to be the student s situation and if you are providing support of any kind. If you should need more space to explain, please attach a letter. _____ _____ _____ _____ _____ I certify that all of the information on this form is true and completed to the best of my knowledge. I also understand that I may be contacted if further information is needed. _____ _____ Name of Reference (please print) Official Title or Relationship to Student _____ _____ Signature Telephone Number _____ _____ Street Address, Box, Etc. Best Time to be Reached _____ _____ City, State, and Zip Date ACKNOWLEDGMENT STATE OF _____) ) COUNTY OF _____) On this _____day of _____20_____, before me, the undersigned Notary Public, personally appeared _____ to me known to be the individuals(s) described in and who executed the foregoing instrument, and acknowledged that he (she) (they) executed the same as his (her) (their) free act and deed.