SSS Dependent Verification Form 2020-2021



2022-2023 Dependent Verification
Thank you for your interest in NCMC's Student Support Services program! Please complete this Dependent Verification Form as thoroughly as possible. This form is designed to be completed by a Parent or Legal Guardian. The information on this form is based on your 2021 Taxable income. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit the verification form. If you have any questions, please call our office at (660) 357-6332.
Student Name *
Parent/Legal Guardian Name(s) *
Parent/Legal Guardian(s) Phone Number
Did the mother of this student earn a 4-year degree from a college or university? * Yes No
Did the father of this student earn a 4-year degree from a college or university? * Yes No
Number of people living in parent/legal guardian's household? * 1 2 3 4 5 6 7 8+
* What was the parent/legal guardian's 2021 Taxable income? *
Notes
* This is NOT adjusted gross income. This amount is listed on IRS Form 1040 - Line 15.
Parent/Legal Guardian Signature * Please select a signature verification type.
Terms of Submission: I understand that Student Support Services will use the data provided on this form to assist in assessing my child's eligibility for the Student Support Services Program at NCMC and that all of the information will be kept confidential. I certify that the information on this application is true and correct to the best of my knowledge.

2022-2023 Dependent Verification

Thank you for your interest in NCMC's Student Support Services program! Please complete this Dependent Verification Form as thoroughly as possible. This form is designed to be completed by a Parent or Legal Guardian. The information on this form is based on your 2021 Taxable income. You may want to review the included items, take some time to make notes and gather the required documents, and then return to submit the verification form. If you have any questions, please call our office at (660) 357-6332.

Student Name *

Parent/Legal Guardian Name(s) *

Parent/Legal Guardian(s) Phone Number

Did the mother of this student earn a 4-year degree from a college or university? *

Did the father of this student earn a 4-year degree from a college or university? *

Number of people living in parent/legal guardian's household? *

* What was the parent/legal guardian's 2021 Taxable income? *

Notes

* This is NOT adjusted gross income. This amount is listed on IRS Form 1040 - Line 15.

Parent/Legal Guardian Signature *

Please select a signature verification type.

Terms of Submission:
I understand that Student Support Services will use the data provided on this form to assist in assessing my child's eligibility for the Student Support Services Program at NCMC and that all of the information will be kept confidential. I certify that the information on this application is true and correct to the best of my knowledge.