H:\ss\financial aid\Financial Aid FORMS\Dependent Care Allowance form.doc
Dependent Care Allowance Request Form
Rush University
Office of Student Financial Aid
Federal regulations permit the Financial Aid Office to increase a student’s educational cost of education budget by
creating an allowance for costs expected to be incurred for dependent care. The amount of the allowance is to be
based on the number and age of such dependents and should not exceed a reasonable cost. The reasonable cost basis
is the child care cost charged by Lawrence Armour Day School at RUMC, otherwise referred to as the “community
standard”.
The dependent care allowance is for the express purpose to enable the student to attend class, clerkship programs, or
some other educational activity required by the respective program of study to complete the required program of
study. Additional costs for maintenance are already included in the budget and can be reviewed with a financial aid
counselor.
The dependent care allowance will only be approved for the student actually paying the expense; both parents of a
two-student household may NOT use the same allowance.
Student Name: __________________________________________ Student ID: ________________________
SECTION A: To be Completed by student requesting a Dependent Care Allowance component in financial aid award. A
separate form is required if using different child care provider for different child(ren).
Name of Child Age Weekly Rate
___________________________________ ___________ ______________
___________________________________ ___________ ______________
___________________________________ ___________ ______________
___________________________________ ___________ ______________
I/We certify that all of the information on this form is complete and correct. I/We understand that both parents
cannot request a dependent care allowance for the same dependent(s).
Student Signature _________________________________________________ Date _____________
Spouse Signature __________________________________________________ Date _____________
SECTION B: To be completed by the dependent care provider
Care provided for each child above From To Weekly Rate
Child’s Name ____________________ ___/___/___ ___/___/___ $ ____________
Child’s Name ____________________ ___/___/___ ___/___/___ $ ____________
Child’s Name ____________________ ___/___/___ ___/___/___ $ ____________
Child’s Name ____________________ ___/___/___ ___/___/___ $ ____________
I confirm that the expected dependent care expenses I have listed above are an accurate projection of expected
dependent care expenses and are not being paid for by any source other than the student.
Signature ______________________________________________________ Date _____________
