20162017 Verification Worksheet
Dependent Student
A. Dependent Student’s Information
________________________________ _____________________________________ ___________________
Student’s Last Name Student’s First Name Student #
____________________________________________ _________________________________________
Student’s Email Address Student’s Phone Number (include area code)
B. Dependent Student’s Family Information
List below the people in your parent (s)’ household. Include yourself and your parent(s), (stepparent if applicable) even if you don’t live with your parent(s).
Include anyone who will receive more than half of their support from July 1, 2016, through June 30, 2017 from your parents. Include the name of the college
for any household member, excluding your parent(s), who will be enrolled, at least half time in a degree, diploma, or certificate program at a postsecondary
educational institution any time between July 1, 2016, and June 30, 2017. Attach a separate page if needed.
Full Name
Age
Relationship
College
Will be Enrolled at
Least Half Time
Self
C. Dependent Student’s Income Information to Be Verified
Untaxed Income
I received sources of untaxed income in 2015. (Sources may include payments to tax-deferred pension/retirement savings,
child support received, housing, food, and other living allowances paid to members of the military, clergy, and others, veterans
non-education benefits, workers’ compensation, state disability, Black Lung benefits, untaxed portions of health savings
accounts, railroad retirement benefits, unemployment benefits, general relief, alimony, money received or paid on the your
behalf or any other untaxed income received in 2015. Do not include social security benefits, Supplemental Security Income
(SSI), Workforce Investment Act (WIA) educational benefits, TANF, combat pay, benefits from flexible spending arrangements).
I have indicated the source and the amount below.
Sources of Untaxed Income (Student)
2015 Amount
Total
Filed a tax return
I used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and successfully transfer my 2015 IRS income information
into the FAFSA. Skip to Section D.
2015 IRS tax return transcript is attached. Please write your name and student number on transcript. Skip to Section D.
Did not file a tax return
I was not employed and had no income earned from work in 2015.
I was employed in 2015, but am not required to file taxes. Listed below are the names of the employer and the amount earned.
W-2 forms are attached.
2015 Amount Earned
IRS W-2 Attached?
Your 20162017 financial aid application was selected for review in a process called verification. We will compare your application with the information on this
worksheet and with any other required documents. If there are differences, your application information may need to be corrected. You and at least one parent must
complete and sign this worksheet, attach any required documents, and submit this form and other required documents to the Financial Aid Office.
D. Parent’s Income Information to Be Verified
Untaxed Income
My parents received sources of untaxed income in 2015. (Sources may include payments to tax-deferred pension/retirement
savings, child support received, housing, food, and other living allowances paid to members of the military, clergy, and others,
veterans non-education benefits, workers’ compensation, state disability, Black Lung benefits, untaxed portions of health
savings accounts, and railroad retirement benefits, unemployment benefits, general relief, alimony, money received or paid on
the your behalf or any other untaxed income received in 2015. Do not include social security benefits, TANF, combat pay,
benefits from flexible spending arrangements). I have indicated the source and the amount below.
Sources of Untaxed Income - Parent(s)
2015 Amount
Parent(s) filed a tax return
My parent(s) used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and successfully transfer their 2015 IRS income
information into the FAFSA. Skip to Section E.
2015 Parent(s) IRS tax return transcript is attached. Write the student’s name and student number on transcript. Skip to E.
Parent(s) did not file a tax return
My parent(s) was/were not employed and had no income earned from work in 2015.
My parent(s) was/were employed in 2015 and were not required to file a tax return. Listed below are the names of the employer
and the amount earned. W-2 forms are attached.
2015 Amount Earned
IRS W-2 Attached?
E. Additional Information Other Support Received
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
F. Student and/or Parent’s Other Information to Be Verified
Check the box below if someone in the student’s parent’s household (listed in Section B) received benefits from the
Supplemental Nutrition Assistance Program (SNAP-food stamps) any time during the 2014 or 2015 calendar years.
One of the persons listed in Section B of this worksheet received SNAP benefits in 2014 or 2015.
Check the box below and complete the section below if you or one or both of your parents paid child support in 2015.
Myself or One (or both) of my parents listed in Section B of this worksheet paid child support in 2015. I have indicated below the
name of the person who paid the child support, the name of the person to whom the child support was paid, the names of the
children for whom child support was paid, and the total annual amount of child support that was paid in 2015 for each child. If
asked by the school, I will provide documentation of the payment of child support. If you need more space, attach a separate page
that includes the student’s name and Student Number at the top.
Name of Person Who Paid
Child Support
Name of Person to Whom
Child Support was Paid
Name of Child for Whom
Support Was Paid
Amount of Child
Support Paid in 2015
G. Certification and Signatures
Each person signing this worksheet certifies that all of the information reported is complete and correct. The
student and one parent must sign and date.
_________________________________________________ _________________________________
Student’s Signature Date
_________________________________________________ _________________________________
Parent’s Signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.