STUDENT NAME:_______________________________________ ID#: 9200
On your application for financial aid, you indicated that you or your parents (if a dependent student) are separated. In
order for us to complete your file review, you need to provide documentation verifying this status for you or your parents
Name of person completing form: ______________________________________________________________
I am □ Parent □ Student
Please check one:
I am divorced and have not remarried. Date of divorce: ___________________. Please include a copy of your
I divorced but have remarried. Date of remarriage: ____________________. Please include a copy of your new
spouse’s signed 2010 federal tax return.
I separated from my spouse and we are presently maintaining separate households. We have been separated since
____________. Please provide documentation of this status to include (but not limited to): pre-divorce and or
legal separation documents, copies of separate rental housing agreements or mortgage contracts, copies of
separate utility bills, etc.
If you and your spouse still live in the same house or maintain separate residences due to military or employment
requirements, you are not considered separated. If you are not separated from your spouse, check the space below and
return a copy of your spouse’s signed 2010 federal tax return.
I am not divorced or separated from my spouse. (If you check this option, disregard the next section.)
Please list below the financial support received from spouse, if any:
$ ___________________ child support/cash payment from spouse received in 2010
$ ___________________ other means of support (housing or living allowances received from spouse or anyone
else) received in 2010.
I certify that the information provided in this petition is true and correct. WARNING: If you purposely give false or
misleading information on this form, you may be fined, sentenced to jail, or both.
Signature: __________________________________________________ Date: _______________________________
Please allow up to 4 weeks for processing