Allegheny College Financial Aid Office
Dependent Student Verification Statement
Allegheny College
2013-2014
Student______Allegheny Student I.D. Number______Email Address______
Address______
Street/P.O. Box City State Zip Code
Cell Phone Number_(_____)______Home Phone Number__(_____)______
1. Family Information
List the people in your parents’ household, include:
· yourself and your parents (stepparent)
· your parents’ other children even if they don’t live with your parent(s) if your parents will provide more than half their support
· other people if they now live with your parents, and your parents provide more than half of their support and will continue to provide more than half of their support from July 1, 2013 through June 30, 2014
Write the names of all household members in the space(s). Also write in the name of the college for any family member (excluding parents) who will be attending college at least half-time between July 1, 2013 and June 30, 2014 and will be enrolled in a degree, diploma or certificate program. If you need more space, attach a separate page.
List EVERYONE Who Lives Age Relationship If They Attend College, Will be Enrolled
In Your Home To Student List Name of College at least Half-time
(Yes or No)
Self Allegheny College Y N
Custodial Parent N/A
Custodial Parent/Stepparent N/A
Sibling Y N
Sibling Y N
Y N
______Y N
2. Parents’ 2012 Tax Forms and W-2 Wage Statements
If you have not already sent a SIGNED copy of your parents' 2012 federal tax return, please send a SIGNED copy with this statement. Your parents must include a copy of the W-2 wage statements issued from their employer. The Declaration of Electronic Filing (Form 8453) is NOT a tax return; please print a 1040, 1040A, or 1040EZ. If they are filing for a tax extension, include the request for an extension (Form 4868) along with their W-2’s. If your parents are not required to file a 2012 Federal Tax Return, please complete a Statement of Non-Filing form (available from our office) and send it with this Verification Statement.
3. Parents’ Untaxed Income
Amounts received for child support, Social Security, and other untaxed income. (See worksheets A & B of the FAFSA.)
List amounts received for parents and all dependent children, including you.
DO NOT LEAVE BLANK IF THE ANSWER IS ZERO, PUT "0" IN THE SPACE PROVIDED
Sources of Untaxed Income /2012 Amount
/ Sources of Untaxed Income /2012 Amount
a. Social Security (non-taxed)* / $ / d. Payment to tax deferred retirement plan. / $b. Child Support Received / $ / e. Workmen’s Comp. / $
c. Welfare (including TANF) / $ / f. Other: / $
*Attach a copy of your Social Security benefit statements with yearly totals for everyone in the home receiving benefits.
4. Income Exclusion
List the amount of work-study earnings student received in 2012: $______
Child support paid by parents listed, under Section I above, to other children not living in the parents' household:
$______List recipients: ______
5. Student’s Income Information
Do not include any amounts listed under parents’ untaxed income.
You must check one:
q Check and attach a signed copy of the student’s 2012 federal tax return.
q Check and complete: signed copy of student’s federal tax return will be submitted to the school by______(date).
q Check here if you (student) will not file and are not required to file a 2012 U.S. federal income tax return.
If you (student) did not file and are not required to file a 2012 Federal income tax return, list below your employer(s) and any income you received in 2012.
Sources of all Student Income (Use W-2 form or other earnings statements) /2012 Amount
$$
$
Total Amount / $
*IF THE ANSWER IS ZERO, PUT "0" IN THE SPACE PROVIDED*
Sources of Student’s Untaxed Income /2012 Amount
/ Sources of Student’s Untaxed Income /2012 Amount
a. Child Support Received(for student’s dependents) / $ / d. Payment to tax deferred retirement plan / $
b. Social Security (non-taxed) / $ / e. Other: / $
c. Welfare (including TANF) / $ / f. Other: / $
6. Scholarships
Do you expect to receive a scholarship or other gift/benefit aid awarded from a source other than Allegheny College for 2013-2014? ____YES ____NO
If yes, please list amounts separately: $______$______$______
Sources: ______
7. Sign this Worksheet
By signing this worksheet, we certify that all
the information reported on it is complete and
correct. At least one parent must sign.
______
Student Signature Required Date
______
Parent Signature Required Date
This form will not be processed without the above signatures; parent/stepparent cannot sign for student.
Please return this completed form to:
Allegheny College
Financial Aid Office
520 North Main Street
Meadville, PA 16335
FAX: 814-332-2349