Statement of Marital Separation

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STATEMENT OF MARITAL SEPARATION

Student’s Name:_____________________________ Soc. Sec. #:______-____-_______

This Statement must be completed if one of the following is true:

1. The student is separated from spouse and does receive no financial support, or

2. The student’s parents are separated and the non-custodial parent does not provide any
financial support.

I, ______________________________________, certify that I am separated from


my spouse, ______________________________________, and I have been separated
since: ______/______/______.

We are not residing at the same address and I am not receiving any support in any form
including the use of his/her car, apartment, or home on a non-paying basis.

I further certify that if I commence living with my husband / wife and / or receive any
form of support in the way of monies or free use of his / her car, apartment, or home.

I will notify the Office of Financial Aid and submit a statement indicating my financial
status at that time.

I also certify that if this temporary separation results in a legal separation or divorce
resulting in court-ordered alimony and / or child support, I will furnish the Financial Aid Office
with a copy or this Court-order.

STUDENT’S SIGNATURE: _______________________________ DATE: _____/_____/_____

PARENT’S SIGNATURE: ________________________________ DATE: _____/_____/_____

*PARENT’S SIGNATURE REQUIRED WHEN PARENTS ARE SEPARATED AND THE NON – CUSTODIAL
PARENT DOES NOT PROVIDE ANY FINANCIAL SUPPORT.

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