Financial Aid Dependent Care Expense Form - Vcu - Virginia- 2016-2017 printable pdf download

2015-2016 FINANCIAL AID DEPENDENT CARE EXPENSE FORM

A dependent care allowance may be added to a student’s cost of attendance providing that the student provides over 50% of the support and that

care for the dependent is required for the student to attend school. Dependents may include elderly or disabled adults or spouse. Please note that the

inclusion of dependent care expenses may not always result in an increased financial aid award. Please fill out the form completely and return to the

VCU Office of Financial Aid.

NAME ____________________________________________________________________

Last

First

Student ID Number

HOME PHONE NUMBER _____________________________________ ALTERNATE/CELL-PHONE NUMBER __________________________

(Including area code)

VCU EMAIL ADDRESS_________________________________________________________

Monroe Park Campus

School of Allied Health Professions, Nursing, or Pharmacy

School of Dentistry

School of Medicine

Please provide the following information about dependent care expenses for your household (child, spouse, parent or siblings). Attach a statement on

agency letterhead from each provider or a signed notarized statement that includes name of the child, amount paid on a weekly basis, and beginning

and ending dates of care for the current academic year.

Name of Family Member

Age

Relationship

Childcare Provider Information

Weekly Expense

Name

Phone Number

Beginning and ending dates of care

Name

Phone Number

Beginning and ending dates of care

Name

Phone Number

Beginning and ending dates of care

Certification Statement and Signature

By signing this form, I certify that the information provided is true and accurate. I understand that any false statement or misrepresentation may

be cause for reduction and/or repayment of federal, state, or institutional financial aid. I agree to provide additional proof of information provided

on this form. I authorize the VCU Office of Financial Aid to contact the provider(s) listed above for additional or clarifying information.

Student Signature ____________________________________________________________ Date _______________________________

(Required)

Office of Financial Aid

Grace E. Harris Hall Student Service Center

1015 Floyd Ave., 1st Floor

P.O. Box 843026

Richmond, VA 23284-2520

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(804) 828-1550

Fax (804) 827-0060

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