Dependency Review Form 2012-2013

PLEASE PRINT

STUDENT SECTION

Student's Name:______________________________________SS#________________

Permanent Address:______________________________________________________

E-mail Address:__________________________________________________________

4. Explain circumstance which justify treatment of student as self-support (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. Action: 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