2016-17 Verification Worksheet
Dependent Student–V5
Your 2016-2017 Free Application for Student Aid (FAFSA) was selected for a review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm the information you and your parents reported on your FAFSA. To verify that you provided correct information the financial aid administrator at your school will compare your FAFSA with the information on this worksheet and with any required documents. If there are differences, your FAFSA information may need to be corrected. You and at least one parent must complete and sign this worksheet, attach any required documents, and submit the form to the financial aid administrator at your school. Your school may ask for additional information. If you have questions about verification, contact your financial aid administrator as soon as possible so that your financial aid will not be delayed.
A. Student Information
______
Last Name First Name M. I.Social Security Number
______
Address (include apt. no.)Date of Birth
______
City StateZip CodePhone Number (include area code)
B. Family Information
List the people in your parent(s)’ household. Include:
- Yourself and your parent(s) (including a stepparent) even if you do not live with your parent(s).
- Your parents(s)’ other children if your parent(s) will provide more than half of their support from July 1, 2016, through June 30, 2017, or if the other children would be required to provide parental information if they were completing a FAFSA for 2016-2017. Include children who meet either of these standards, even if they do not live with your parent(s).
- Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue to provide more than half of their support through June 30, 2017.
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 an eligible postsecondary education institution any time between July 1, 2016, and June 30, 2017. If more space is needed, attach a separate page with the student’s name and Social Security Number at the top.
Full Name / Age / Relationship / College / Will be Enrolled at Least Half TimeMissy Jones (example) / 18 / Sister / Central University / Yes
Self
TAX RETURN FILERS – Important Note: If the student and or parent(s) filed, or will file, an amended2015 IRS tax return, or granted a filing extension by the IRS, the student must contact the financial aid administrator before completing sections C and D.
Instructions: Complete these sections if the student and or parent(s), filed or will file a 2015 income tax return with the IRS. The best way to verify income is by using the IRS Date Retrieval Tool that is part of FAFSA on the Web. If the student has not already used the tool, go to FAFSA.gov, log in to the student’s FAFSA record, select “Make FAFSA Corrections,” and navigate to the Financial Information section of the form. From there, follow the instructions to determine if the student is eligible to use the IRS Data Retrieval to transfer 2015 IRS income tax information into the student’s FAFSA. It takes up to 2-3 weeks for the IRS income information to be available for the IRS Data Retrieval Tool for electronic IRS tax return filers, and up to 8-11 weeks for paper IRS tax return filers. If you need more information about when, or how to use the IRS Data Retrieval Tool see your financial aid administrator.
C. Student’s Tax Forms and Income Information (all applicants)
1. Check only one box below. Tax transcripts include the 2015 IRS transcript filing Form 1040, 1040A, and 1040EZ.
Check here if you are updating your 16-17 FAFSA by using the IRS Data Retrieval Tool.
Check here if you are attaching a copy of your tax transcript.
Check here if a tax transcript will be submitted to the school or will be using the IRS Data Retrieval Tool
Check here if you were not employed and had no income earned from work in 2015.
2. If you did not file and are not required to file a 2015 Federal income tax return, list below your employer(s) and any income received in 2015(You must provide the W-2 form or other earnings statements with this form).
Employer’s Name / 2015 Amount Earned / IRS W-2 Attached?Suzy’s Auto Body Shop (example) / $2,000.00 (example) / Yes (example)
D. Parent(s)’ Tax Forms and Income Information
1. Check only one box below. Tax Transcripts include the 2015 IRS transcript from filing Form 1040, 1040A and 1040EZ.
Check here if your parents are updating your 16-17 FAFSA by using the IRS Data Retrieval Tool.
Check here if your parents are attaching a copy of their tax transcript.
Check here if a tax transcript will be submitted to the school or will be using the IRS Data Retrieval Tool
Check here if your parent(s) was not employed and had no income earned from work in 2015.
2. If your parents did not file and are not required to file a 2015 Federal income tax return, list below employer(s) and any income received in 2015(You must provide the W-2 form or other earnings statements with this form).
Employer’s Name / 2015 Amount Earned / IRS W-2 Attached?Suzy’s Auto Body Shop (example) / $2,000.00 (example) / Yes (example)
E. Supplemental Nutrition Assistance Program or SNAP (formerly known as food stamps)
Did you or someone in your parent’s household receive SNAP in 2014or 2015 ___ Yes ___ No
Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we
may require documentation from the agency that issued the SNAP benefits in 2014 or 2015.
F. Child Support Paid
If one of the parents included in the household of the student paid child support in 2015 complete the following.
Name of Person Who Paid Child Support / Name of Person to Whom Child Support was Paid / Name & Age of Child for Whom Support was Paid / Annual Amount of Child Support Paid in 2015Mary Jones / Chris Smith (example) / Terry Jones / $6,000.00
Note: If we have reason to believe that the information regarding child support paid is not accurate, we may require
additionaldocumentation.
G. High School Completion Status______
Provide one of the following documents that indicatethe student’s high school completion status when the student will begin college in 2016–2017:
- A copy of the student’s high school diploma.
- A copy of the student’s final official high school transcript that shows the date when the diploma was awarded.
- A copy of the student’s General Educational Development (GED) certificate, an official GED transcript that indicates the student passed the exam, or a state-authorized high school equivalent certificate.
- An academic transcript that indicates the student successfully completed at least a two-year program that is acceptable for full credit toward a bachelor’s degree.
- For a homeschooled student from a state where state law requires the student to obtain a secondary school completion credential for homeschool (other than a high school diploma or its recognized equivalent), a copy of that credential.
- For a homeschooled student from a state where statelaw does not require the student to obtain a secondary school completion credential for homeschool (other than a high school diploma or its recognized equivalent), a transcript or the equivalent, signed by the student’s parent or guardian, that lists the secondary school courses the student completed and includes a statement successfully completed a secondary school education in a homeschool setting.
If the student is unable to obtain the documentation listed above, he or she must contact the financial aid office.
H. Identity and Statement of Educational Purpose(To Be Signed at the Institution)______
The student must appear in person at ______to
(Name of Postsecondary Educational Institution)
verify his or her identity by presenting an unexpired valid government-issued photo identification (ID), such as, but not limited to,a driver’s license, other state-issued ID, or passport. The institution will maintain a copy of the student’s photo ID that is annotated by the institution with the date it was received and reviewed and the name of the official at the institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional official, the Statement of Educational Purpose provided below.
Statement of Educational Purpose
I certify that I ______am the individual signing
(Print Student’s Name)
this Statement of Educational Purpose and that the Federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending
______for 2016-2017.
(Name of Postsecondary Educational Institution)
______
(Student’s Signature) (Date)
______
(Student’s ID Number)
(To Be Signed in the Presence of a Notary)
If the student is unable to appear in person at ______
(Name of Postsecondary Educational Institution)
to verify his or her identity, the student must provide to the institution:
(a) A copy of the unexpired valid government-issued photo identification (ID) that is acknowledged in the
notary statement below or that is presented to a notary, such as, but not limited to, a driver’s
license, other state-issued ID, or passport; and
(b) The original Statement of Educational Purpose, which is provided below, must be notarized.
If the notary statement appears on a separate page than the Statement of Educational
Purpose, there must be a clear indication that the Statement of Educational Purpose was
the document notarized.
Statement of Educational Purpose
I certify that I ______am the individual signing
(Print Student’s Name)
this Statement of Educational Purpose and that the Federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending
______for 2016-2017.
(Name of Postsecondary Educational Institution)
______
(Student’s Signature) (Date)
______
(Student’s ID Number)
Notary’s certification may vary by State
State of ______
City/County of ______
On______, before me, ______,
(Date) (Notary’s name)
personally appeared, ______, and proved to me
(Printed name of signer)
on basis of satisfactory evidence of identification______
(Type of government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
(seal) ______
(Notary signature)
My commission expires on ______
(Date)
J. Sign this Worksheet______
Each person signing this form certifies that all the information
reported on it is complete and correct. The student and one______
parent whose information was reported on the FAFSA Student’s SignatureDate
must sign and date.
______
Parent’s SignatureDate