2016-2017 Independent Status Determination Form

Financial Aid Office
1000 East Victoria Street
Carson, CA 90747
(310) 243-3691 · Fax (310) 516-4498
Name: _______________________________________________
Last
First
MI
Student ID# __________________________________________
2016-2017 Independent Status Determination Form
According to the information we received from your completed 2016-2017 Free Application for Federal Student
Aid (FAFSA), you answered “Yes” to one or more of the following questions. To determine if you are an
Independent student, you must submit supporting documents as described below:

At any time since you turned age 13, were both your parents deceased, were you in foster care or were you
a dependent or ward of the court? Attach a copy of your birth certificate and a copy of a death certificate
for your parent(s).

Are you or were you an emancipated minor as determined by a court in your state of legal residence?
Attach court documentation.

Are you or were you in legal guardianship as determined by a court in your state of legal residence? Attach
court documentation.

At any time on or after July 1, 2015 did the director of a runaway or homeless youth basic center or
transitional living program determine that you were an unaccompanied youth who was homeless or were
self–supporting and at risk of being homeless? Attach supporting documentation.

At any time on or after July 1, 2015 did your high school or school district homeless liaison determine that
you were an unaccompanied youth who was homeless or self-supporting and at risk of being homeless?
Attach supporting documentation.

At any time on or after July 1, 2015 did the director of an emergency shelter or transitional housing
program funded by the U.S. Department of Housing and Urban Development determine that you were an
unaccompanied youth who was homeless or were self-supporting and at risk of being homeless? Attach
supporting documentation.

I incorrectly answered one or more of the above questions on my FAFSA and I will make corrections to my
FAFSA application as the Financial Aid Office is unable to continue processing my application.
If you have other special circumstances you feel should be considered, please review the 2016-2017 Dependency
Override Request Form available on the Financial Aid Office website.
CERTIFICATION AND SIGNATURE
WARNING: If you purposely give false or
misleading information you may be fined,
be sentenced to jail, or both.
The person signing below certifies that all of the
information reported is complete and correct.
________________________________________________
Student’s Signature (Required)
__________________________
Date