NAME: STUDENT ID:
ADDRESS:
PHONE: E-MAIL:
With whom do you currently live?
How long have you lived with this person/family? years months
How much do you pay in rent and utilities per month? $
Can you provide parental information for the FAFSA? __________________
Father’s name:
Address:
When did you last live with your Father?
(month/year)
When was the last time you had contact with your Father?
(month/year)
When did your Father last provide financial support for you?
(month/year)
How often do you have contact with your Father?
Mother’s name:
Address:
When did you last live with your Mother?
(month/year)
When was the last time you had contact with your Mother?
(month/year)
When did your Mother last provide financial support for you?
(month/year)
How often do you have contact with your Mother?
___________________________________________ DATE ____________
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
2023-2024 DEPENDENCY OVERRIDE REQUEST
Phone: Fax:
Address:
Email:
(559) 494-0312 (800) 643-0932 995 N. Reed Ave.
reedley.financialaid@reedleycollege.edu
INSTRUCTIONS:
1)
If you have not submitted a FAFSA for this yea
r, apply at www.fafsa.gov
2) Attach a typewritten explanation regarding your relationship with your parents, why you no longer
live with your
parents, why you no longer have contact, and why they do not financially support you.
3) Attach your Third Party Documentation letter (instructions at end of form)
4) Attach an
y legal documents or any other paperwork regarding your situation.
STUDENT
’S
DEMOGRAPHICS
ST
UDENT’S
PRESENT LIVING
AR
RANGEMENTS
FATHER’S
INFORMATION
MOTHER’
S
INFORMATION
STUDENT
CERTIFICATION
I certify that the information provided is true and correct. I understand that any
false statements of misrepresentations will be cause for denial, reduction,
cancellation, or repayment of financial aid.
STUDENT
SIGNATURE
$
$
$
$
Complete this section if your income reported on this form is less than $5,000. In the box below, explain how you met your monthly
expenses: low income housing, SNAP, cash aid, social security benefits, etc.
STUDENT INCOME INFORMATION
Check the box that applies:
I filed taxes and have used the IRS Data Retrieval Tool to retrieve and transfer my 2021
IRS income information into the FAFSA.
I filed taxes and am unable to use the IRS Data Retrieval Tool on my FAFSA. Attached is a
copy of my 2021 IRS tax return transcript.
To obtain an IRS tax return transcript, call 1-800-908-9946; photocopied tax returns are no longer accepted.
You will need your Social Security Number and the address on file with the IRS to request a transcript.
I did not file taxes in 2021.
Attach all 2021 IRS W-2 forms issued to me by my employer(s).
I was not employed and had no income from work in 2021.
If you earned wages in 2021, list all income earned below. List every employer even if they did not issue an IRS
W-2
form.
(If more space is
needed, attach a separate page with your name and school ID number at the top of the
page.)
Employer’s Name 2021 Amount Earned IRS W-2 Attached?
Check this box if you received benefits form the Supplemental Nutrition
Assistance Program (SNAP),formerly known as food stamps, any time during 2021
or 2022.
Check this box and complete this section if you paid child support during 2021 :
Name of person who child support was paid
to:
Name of child who support was paid for: Total amount of child support paid
in 2021:
SUPPORT CERTIFICATION
This document contains both information and form fields. To read information, use the Down Arrow from a form field.
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$
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$
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$
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$
$
$
St
udent Signature:
Date:
2023-2024 DEPENDENCY OVERRIDE REQUEST
A
DDITIONAL INCOME AND ASSET INFORMATION FOR STUDENT
DO NOT LEAVE THIS SECTION BLANK: Enter yearly amount for 2021 or $0 if none.
Child Support RECEIVED – DO NOT include foster care payments
Payments to tax-deferred pension and savings plan (paid directly or withheld from earnings)
including amounts reported on the W-2 in box 12a through 12d codes D, E, F, G, H, and S
Housing, food, or other allowances paid to members of the military, clergy, and others (including
cash payments and cash value of benefits)
Veteran’s non-education benefits such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC) and/or VA Educational Work Study allowances
Non-Federal Disability Benefits, Untaxed Pensions or Workers Compensation (Do not include any
type of Social Security Benefits)
Unemployment benefits that were not reported on your tax return
Any money given to you by someone else (for bills, rent, utilities, etc.)
At the time of filing your FAFSA, what was the total balance of your cash, savings and checking
accounts?
At the time of filing your FAFSA, what was the net worth of your investments, including real
estate*?
*DO NOT INCLUDE THE VALUE OF THE HOME YOU LIVE
IN.
Current
value minus debts related to the investments = NET WORTH.
At the time of
filing your FAFSA, what was the net worth of your farm, including market value
of land, buildings, machinery, equipment, inventory, etc.?
Current value minus debt for which the farm was used as collateral = NET WORTH.
Check here if your family lives on and operates the farm
At the time of filing your FAFSA, what was the net worth of your business, including market
value of land, buildings, machinery, equipment, inventory, etc.?
Current value minus debt for which the business was used as collateral = NET WORTH.
Check here if your business is owned & controlled by your family and has fewer than 100
employees
REQU
IRED SIGNATURES
By signing below, I certify the information reported on this worksheet is complete and accurate. If asked by the
college, I agree to provide proof of any information reported on this form or on my FAFSA. I realize that any false
statement or failure to give proof when asked may be cause for the denial, reduction, withdrawal, and/or repayment
of my financial aid. I also understand if I purposely give false or misleading information I may be fined up to
$20,000, sentenced to jail, or both.
FD23CDOV
Revised 11/7/2022
Instructions for Third Party Documentation
In extraordinary and documented cases, the Financial Aid Office has authority to use professional
judgment to override a student’s dependency status in order to make a student independent for
financial aid purposes.
Parents’ unwillingness to provide the information or inability to help support the student are not
acceptable reasons for a dependency override; a student must be unable to obtain his/her parents’
information because of extenuating circumstances. The information stated in the Dependency
Override Request must be verified by a third party who is aware of the student’s home situation
and can verify the information provided on the Dependency Override Request. Examples of such a
person include, but are not limited to: employer, clergy, social worker, attorney, court official,
teacher, counselor, psychiatrist, psychologist, medical professional, law enforcement agent, etc.
INSTRUCTIONS FOR THIRD PARTY REFERENCE:
Third party documentation must be on a SEPARATE sheet of letterhead paper. Please include any
information for which you have first hand knowledge and that you feel best describes the student’s
situation. The following is a list of information that MUST be included in your letter:
• How long have you known the student,
• Your relationship to the student,
• When was the last time the student lived with and/or received financial support from
his/her parents,
• Any knowledge of his/her relationship with their parents, and
• The steps that the student has taken to establish their independence from his/her
parents.
Please make sure to include your professional title, name and type of business, business address,
telephone number, and where to contact you should any additional information be required.
DEPENDENCY OVERRIDE REQUEST FORMS WILL NOT BE ACCEPTED WITHOUT THE
THIRD-PARTY DOCUMENTATION LETTER
