Dependent Verification Form
These types of forms are used for a variety of purposes. There are dependent verification forms that are used to verify a dependent’s insurance status upon attaining the mandatory expiry date. There are also other dependent verification forms that are used for the application of federal student aid funds. They simply seek to verify eligibility of the person in question to the respective purpose.
Sample Dependent Verification Form
Section A: Must be completed
1. My dependent is single:
Yes No Date of Marriage (MM/DD/YY): ____/____/____ (go to Section E)
2. My dependent receives at least 50% of his/her financial support from me or the other parent as demonstrated by the support test for federal income tax purposes that is described in IRS Publication 501 (whether or not the dependent is claimed on the parent’s federal return):
Section B: Full-Time Student Status (Refer to the next page for the definition)
3. My dependent will be enrolled as a full-time student at an accredited educational institution in 2009 (full-time status is defined by the institution):
Yes Name of School: ___________________________________________________
City/State of School: ________________________________________________
Expected Graduation Date (Month/Year): _______/_______
To the best of my knowledge, all statements and answers above are complete and true.
X____________________________________________ ____________________
Subscriber’s Signature Date.
Category: Verification Forms






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