MORGAN COMMUNITY COLLEGE

MINOR STUDENT’S STATEMENT FOR EMANCIPATION CLAIM

Student Name: ______MCC Student ID:______

Student Birthdate: ______Student Age: Social Security Number: ______

Student Address for Reply:

Street______

Street______

City______State______Zip_____

Home or Cell Phone______

Student Permanent Address:

Street ______

Street______

City______State______Zip_____

Home or Cell Phone______

Complete the following questions ONLY IF:

(a) you are under 23 years of age and emancipated, or

(b) you have turned 23 in the past 12 months and were emancipated prior to turning 21.

SECTION 1

  1. Attach copies of your parent’s federal income tax returns during your period of emancipation

andhave your parent(s) complete page 3 of this form.

  1. List all financial support provided to you by your parents during the past 15 months.

Month 15______Year______Amount______

Month 14______Year______Amount______

Month 13______Year______Amount______

Month 12______Year______Amount______

Month 11______Year______Amount______

Month 10______Year______Amount______

Month 9______Year______Amount______

Month 8______Year______Amount______

Month 7______Year______Amount______

Month 6______Year______Amount______

Month 5______Year______Amount______

Month 4______Year______Amount______

Month 3______Year______Amount______

Month 2______Year______Amount______

Month 1______Year______Amount______

  1. List the last year your parents claimed you as a dependent for purposes of income taxation: ______
  1. List your parents’ home address and the dates you resided there in the past two years:

AddressDates Resided

(Month/Year)

______From______to______

______From______to______

______From______to______

SECTION 2

List your sources of income from employment, loans, school sources, personal savings, trust funds and gifts from your parents, relatives, and friends, since your parents ceased providing financial support:

SourceAddressDateAmount

______

______

______

______

______

You must attach verifying proof and documentation for each income source during the past 12 months.

If your income is provided by a trust fund, furnish written documentation (such as photocopies of legal papers setting up the trust) of the purpose for which the fund was formed, the date it was established, and the dates, amounts, and the persons by whom any money was added to the trust fund in the past 15 months.

If you have savings, they must be documented by photocopies of balance statements or passbook pagescovering the entire 12 month period.

If employment is used as an income source, list in terms of yearly take-home totals (as documented byW-2 forms, statements from employers, etc.), rather than in terms of wages per hour, per week, or per month.

SECTION 3

List and compute your expenses for the past twelve months:

Room per month______= Total for year______

Board per month______= Total for year______

Tuition and fees per term______= Total for year______

Miscellaneous per month______= Total for year______

SECTION 4

I hereby swear/affirm that the answers given in this petition are accurate and complete, and that all documents attached hereto are true and unaltered copies of the original documents requested. If my circumstances change, affecting the tuition status requested by this petition, I agree to notify the Registrar’s Office in writing within 15 days of such change.

______

Signature of Petitioner

IMPORTANT: SIGNATURE OF STUDENT/PETITIONER MUSTBENOTARIZED

State of ______)

County of______)

Sworn and subscribed before me this

______day of ______, ______

Signature of Notary Public

My Commission Expires: ______(SEAL)

MORGAN COMMUNITY COLLEGE

PARENT(S) STATEMENT FORMINOR CLAIMING EMANCIPATION

SECTION 6

I (We), ______, the parent(s)

of______have entirely surrendered the right to care, custody,

(Minor’s Name)

and earnings of ______as of ______/______/______.

(Minor’s Name)Month/Day/Year

SECTION 7

The last time this minor was claimed by me (us) as a state or income tax exemption was ______/______/______, and

Month/Day/Year

he/she will not be so claimed in this or subsequentyears. The only support I (we) have provided to this minor since

emancipation has been______

______

______.

SECTION 8

Attached are photocopies of all federal income tax returns (not W-2 forms) covering the above period of emancipation.

SECTION 9

The emancipation referred to herein is an absolute emancipation for all purposes whatsoever, and was not done for the purpose of tuition classification.

______

Signature of Parent(s)Date

______

Signature of Parent(s)Date

IMPORTANT: SIGNATURE OF PARENT(S) MUST BE NOTARIZED

State of ______)

County of______)

Sworn and subscribed before me this

______day of ______, ______

Signature of Notary Public

My Commission Expires: ______(SEAL)

NOTE:IF UPON PERIODIC RE-EXAMINATION OF AN INDIVIDUAL’S STATUS AS AN EMANCIPATEDMINOR, IT APPEARS THAT HE/SHE IS NO LONGER EMANCIPATED, THE STUDENT IS SUBJECT TO BEING RE-CLASSIFIED AS A NON-RESIDENT FOR TUITION PURPOSES. EVIDENCE THAT A MINOR IS NO LONGER EMANCIPATED MAY INCLUDE SUPPORT BY PARENT(S) OR BEING CLAIMED AS A TAX EXEMPTION BY PARENT(S).

Student Services/ Forms/ EMANCIPATION FORM Input to Student Record: ______(Date & Initials)

Rev.03/01/2010 Permanent Document: PETIT Page 1 of 3