Dependency Review Form 2013-2014

PLEASE PRINT

STUDENT SECTION

Student's name:______________________________________SS#________________

Permanent address:______________________________________________________

Email:__________________________________________________________

4. Explain circumstance which justify treatment of student as self-supporting (attach other sheets as necessary):_____________________________________________________________

5. Attach documentation; describe below.

Nature of documentation:___________________________________________________

Source:__________________________________________ Date received:__________

Nature of documentation:___________________________________________________

Source:__________________________________________ Date received:__________


Student signature:_________________________________________________________

SCHOOL SECTION:6. approved:_____________ denied:_____________ date:___________

Additional information requested:__________________________________Date requested:______

Staff:_________________________________________

Mail or fax this form along with documentation of your circumstances to:


Financial Aid Office
Empire State College
111 West Ave.
Saratoga Springs, NY 12866

FAX: 518-581-2782
Phone: 518-587-2100