2024-2025 Dependents You Support

2024-2025 Dependents You Support

Financial Aid Office | 309.341.5283 | finaid@sandburg.edu
Student Name*

First NameLast Name
Student Id#*
Last 4 Digits of Student SSN xxx-xx-*
Student Email*
example@example.com
According to our records, you indicate that you have legal dependents. Please respond to each of the items identified below.*
According to your Financial Aid application, your income does not appear to cover your living expenses. Please itemize your monthly expenses below and identify how you paid each expense. Please give yearly amounts and who paid for each item as requested.
Housing Expense (Rent or Mortgage)
Enter yearly amount
Paid by:
Subsidized Housing?

YesNo
Utilities: Electric, Gas, Water, Cable
Enter yearly amount
Paid by:
Energy Assistance?

YesNo
Food Stamps?

YesNo
Yearly Amount of Food Stamps
Paid by:
Food (Groceries, Dining Out)
Enter yearly amount
Paid by:
Telephone, Cell Phone
Enter yearly amount
Paid by:
Medical Insurance
Enter yearly amount
Paid by:
Transportation: Car Expenses, gas, repairs, insurance
Enter yearly amount
Paid by:
Personal Expenses: Personal hygiene, cleaning supplies, paper products
Enter yearly amount
Paid by:
Entertainment
Enter yearly amount
Paid by:
Please list the annual income received from the following:
Social Security Benefits (SSI)
Enter yearly amount
Temporary Assistance for Needy Families (TANF)
Enter yearly amount
I certify the information provided above is true and complete.
Student Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: