Independent Student: Verification Of Child Support Paid Form - Adelphi University
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12018-2019
STUDENT LAST NAME:
STUDENT FIRST NAME:
AU ID#:
Independent Student: Verification of Child Support Paid
On your 2018-2019 FAFSA you indicated that you, the student, or your spouse, who is a member of your
household, paid child support in 2016. List below the names of the persons who paid the child support, the names
of the persons to whom the child support was paid, the names and ages of the children for whom the child
support was paid, and the total annual amount of child support that was paid in 2016 for each child.
If more space is needed, provide a separate page that includes the student’s name and ID number at the top.
AMOUNT OF
NAME OF PERSON WHO PAID
NAME OF PERSON TO WHOM
NAME AND AGE OF CHILD FOR
CHILD SUPPORT
CHILD SUPPORT
CHILD SUPPORT WAS PAID
WHOM SUPPORT WAS PAID
PAID IN 2016
$
TOTAL PAID IN 2016:
Note: If we have reason to believe that the information regarding child support paid is inaccurate, we may require additional
documentation, such as:
A signed statement from the individual receiving the child support certifying the amount of child support received;
or,
Copies of the child support payment checks, money order receipts, or similar records of electronic payments having
been made.
Certification and Signatures
Each person signing this worksheet certifies that all of the information on it is complete and correct.
Electronic corrections to your FAFSA may be made by our office if there are discrepancies between the information on
this form and the data you filed on your FAFSA. The student must sign and date this form
STUDENT SIGNATURE:
DATE:
WARNING: If you
purposely give false or
misleading information,
SPOUSE SIGNATURE (OPTIONAL):
DATE:
you may be fined, sent
to prison, or both.
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