Financial Aid Office
1200 16th Street
Golden CO 80401
303-273-3301
303-384-2252 fax
finaid@mines.edu
Number of Household Members and Number in College
Student: _______________________________________ Campus Wide I.D.#:________________________

Dependent Students: Students who were required to report parental data on their FAFSA
Those individuals you will be listing below:
 You, the student.
 Your parents (including a stepparent) even if you do not live with your parents.
 Your parents’ other children if your parents will provide more than half of their support from July 1, 2016, through
June 30, 2017, or if the other children would be required to provide parental information if they were completing a
FAFSA for 2016–2017. Include children who meet either of these standards even if the children do not live with your
parents.
 Other people if they now live with your parents and your parents provide more than half of their support and will
continue to provide more than half of their support through June 30, 2017.

Independent Students: Students who were not required to report parental data on their FAFSA
Those individuals you will be listing below:
 You, the student.
 Your spouse, if you are married.
 You and your spouse’s children if you will provide more than half of their support from July 1, 2016, through June 30,
2017, even if the children do not live with you.
 Other people if they now live with you and you provide more than half of their support and will continue to provide more
than half of their support through June 30, 2017.

Instructions:
Step One: Write the names of all household members in the space(s) below, including yourself. Be sure to
reference the above information so all members of the household who qualify are listed. Indicate their age and
relationship to you. You, the student will be listed on the first line.
Step Two: write in the name of the college for any household member, excluding your parent(s) if
dependent, who will be enrolled at least half-time in a degree, diploma, or certificate program anytime
between July 1, 2016 and June 30, 2017.

If more space is needed, provide a separate page with the student’s name and ID number at the top.

Full Name of household
Age Relationship
Name of the College where
Enrolled at Least
members
household members will be
Half Time?
attending
(Yes or No)


Self
CSM





















Note: We may require additional documentation if we have reason to believe that the information regarding the household members
enrolled in eligible postsecondary educational institutions is inaccurate.

By signing below, I certify that all the information reported on this worksheet is complete and correct. At least one
parent must sign (for dependent students). WARNING: If you purposely give false or misleading information on this
worksheet, you may be fined, be sentenced to jail, or both.

Student_____________________________ Date___________ Parent _______________________ Date____________