Parent(s) 2020 Medical/Dental Expense Form (inactive)

The Office of Financial Aid requires the following information to verify the medical/dental expenses your parent(s) reported on your financial aid application.

Please itemize all out-of-pocket medical and/or dental expenses paid by your parent(s) in 2020. Include below the name of the practitioner or agency paid, payment amount and date, and which family member the expenses were for. Do NOT include expenses that were covered by insurance, expenses that were incurred but have not yet been paid, pre-tax insurance premiums, or self-employed insurance premiums already accounted for on your parent’s Form 1040.

Once you have submitted this form, email supporting documentation to finaid@cmc.edu of all payments made for each family member, such as physician’s office or pharmacy account statements showing amount paid, receipts, or cancelled checks. If documentation is not available, please submit a written explanation of how the itemization was completed without supporting documentation. Please do not send copies of medical records
Student/Parent Information
CMC Student Name CMC Student Name First Middle Last
CMC Student ID Number
Must be 8 digits. Currently Entered: 0 digits.
CMC Student Email

Confirm Email Address
Parent Name Parent Name First Middle Last
Parent Email

Confirm Email Address
2020 Expenses
Name of the person/agency paid #1
Family member name #1
Date paid #1 Date paid #1 / MM / DD YYYY
Amount paid #1 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a second 2020 medical/dental expense?

Is there a second 2020 medical/dental expense? Yes No
Name of the person/agency paid #2
Family member name #2
Date paid #2 Date paid #2 / MM / DD YYYY
Amount paid #2 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a third 2020 medical/dental expense?

Is there a third 2020 medical/dental expense? Yes No
Name of the person/agency paid #3
Family member name #3
Date paid #3 Date paid #3 / MM / DD YYYY
Amount paid #3 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a fourth 2020 medical/dental expense?

Is there a fourth 2020 medical/dental expense? Yes No
Name of the person/agency paid #4
Family member name #4
Date paid #4 Date paid #4 / MM / DD YYYY
Amount paid #4 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a fifth 2020 medical/dental expense?

Is there a fifth 2020 medical/dental expense? Yes No
Name of the person/agency paid #5
Family member name #5
Date paid #5 Date paid #5 / MM / DD YYYY
Amount paid #5 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a sixth 2020 medical/dental expense?

Is there a sixth 2020 medical/dental expense? Yes No
Name of the person/agency paid #6
Family member name #6
Date paid #6 Date paid #6 / MM / DD YYYY
Amount paid #6 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a seventh 2020 medical/dental expense?

Is there a seventh 2020 medical/dental expense? Yes No
Name of the person/agency paid #7
Family member name #7
Date paid #7 Date paid #7 / MM / DD YYYY
Amount paid #7 $ Dollars . Cents
Only include out-of-pocket expenses
Is there an eighth 2020 medical/dental expense?

Is there an eighth 2020 medical/dental expense? Yes No
Name of the person/agency paid #8
Family member name #8
Date paid #8 Date paid #8 / MM / DD YYYY
Amount paid #8 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a ninth 2020 medical/dental expense?

Is there a ninth 2020 medical/dental expense? Yes No
Name of the person/agency paid #9
Family member name #9
Date paid #9 Date paid #9 / MM / DD YYYY
Amount paid #9 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a tenth 2020 medical/dental expense?

Is there a tenth 2020 medical/dental expense? Yes No
Name of the person/agency paid #10
Family member name #10
Date paid #10 Date paid #10 / MM / DD YYYY
Amount paid #10 $ Dollars . Cents
Only include out-of-pocket expenses
Is there an eleventh 2020 medical/dental expense?

Is there an eleventh 2020 medical/dental expense? Yes No
Name of the person/agency paid #11
Family member name #11
Date paid #11 Date paid #11 / MM / DD YYYY
Amount paid #11 $ Dollars . Cents
Only include out-of-pocket expenses
Is there a twelfth 2020 medical/dental expense?

Is there a twelfth 2020 medical/dental expense? Yes No
Name of the person/agency paid #12
Family member name #12
Date paid #12 Date paid #12 / MM / DD YYYY
Amount paid #12 $ Dollars . Cents
Only include out-of-pocket expenses
Is there any additional 2020 medical/dental expense?

Is there any additional 2020 medical/dental expense? Yes No
List all additional 2020 medical/dental expense with the name of person/agency paid, date paid, and amount paid
Total 2020 Medical/Dental Expenses $ Dollars . Cents
Certification Statement

Certification Statement We certify that the information listed above is a complete and accurate list of all out-of-pocket 2020 medical/dental expenses.

Parent(s) 2020 Medical/Dental Expense Form (inactive)

Student/Parent Information

2020 Expenses