2024-2025 Child Care/Dependent Care Allowance Certification Form

2024-2025 Child Care/Dependent Care Allowance Certification Form
Campus Location*
If you pay for child care or dependent care, you may request an increase to your cost of attendance (COA). If funds are available to help meet your increased expenses, your award may be increased to help cover these costs.

Please note that additional expenses are usually funded with "self-help" aid in the form of loans. If you are at your yearly federal maximums, your request for increased aid cannot be funded.
Student Information
Name

First NameLast Name
Student ID
Email
example@example.com
Phone Number
Please enter a valid phone number.
Dependents

List the dependents for which you pay dependent care for:

Reimbursement Information

Your Dependent Care Provider is required to sign this worksheet. Please enter their contact information below. They will receive an email inviting them to complete their portion of this form and add their electronic signature. Please remind them to check their Junk email folder if the invitation does not arrive in their inbox. This form cannot be processed without their signature.
Name

First NameLast Name
Email
example@example.com
Dependent Care Provider Certification

We will email your dependent care provider to fill out the information below.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Dependent Care Cost:
Hours per week that you provide dependent care for:
Cost per hour of dependent care:
Total cost per week:
Provider Signature:

Clear
I certify that this information is true and complete to the best of my knowledge.
Date

MonthDayYear
Date
Student Certification
Student Signature*

Clear
I certify that this information is true and complete to the best of my knowledge.
Date

MonthDayYear
Date
Have Questions About Your Financial Aid?

Financial Aid Office Contact Information:

Address: Attn: Financial Aid Office 3240 Fort Rd., Toppenish, WA 98948 | Phone: (509) 865-8502 | Email: financial_aid@heritage.edu
Should be Empty:

Student Information