Southern Unversity And A&m College Child Care Expense Form - 2015-2016

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SOUTHERN UNVERSITY AND A&M COLLEGE
Office of Student Financial Aid
T.H. Harris Annex Building 139A
P.O. Box 9961
Baton Rouge, Louisiana 70813-9961
(225) 771-2790 Office
(225) 771-5898 Fax
CHILD CARE EXPENSE FORM
2015-2016
Name: ____________________________________
SS or SID#: ______________________
This form is to document student’s claim that (S) he has to pay child care while attending school.
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Number of dependent children 12 years old and under _______
Nursery
Before school care
After school care
 Number of dependent (s) who are elderly or disabled _________
 Please indicate name of dependent (s) receiving care: _________________________________________
_________________________________________
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Childcare expense is paid for the following semester
Fall 2015
Spring 2016
Summer 2016
Explain why you must incur child care expenses (or elderly/disabled care expenses) for your dependent(s).
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________
How much do you pay per month? __________________________________________
Please list the name of person or institution that cares for your dependent.
Name: ______________________________________________________________________________
Address: ____________________________________________________________________________
Telephone Number: ___________________________________________________________________
Please submit a copy of the child’s birth certificate and a letter from the care facility (on letterhead) verifying the following
information:
*Dependent’s name
*Payee’s Name
*Period in which care is provided
#Amount paid per month
Copies of cancelled checks or receipts may be submitted along with this form and letter.
I understand that the Office of Student Financial Aid reserves the right to request additional information and/or confirm the
information that is being reported.
I certify that the information that has been provided on this form is complete and accurate.
Student’s Signature: _________________________________________________Date:_________________________________
WARNING: If you purposely give false or misleading information on the worksheet, you may be fined, be sentenced to jail, or
both.
FINANCIAL AID OFICIER:
(
) Accept
( ) Rejected
Comments:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
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COA updated for:
Fall 2015
Spring 2016
Summer 2016
Certified by: ___________________________________
Date: _________________

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