2017 – 2018 Verification Worksheet
Independent Student
Your application was randomly selected for review in a process called “Verification.” Muhlenberg College is required to compare your FAFSA with this worksheet before finalizing any federal financial aid award. If there are differences between your FAFSA application and this information, Muhlenberg College will update your FAFSA and your financial aid eligibility.
A. INDEPENDENT STUDENT’S INFORMATION
______XXX-XX-______
Last Name, First Name, Middle Initial Last 4 digits of Social Security Number
______
Street Address Date of Birth
______
City State Zip Code Primary Phone Number
B. INDEPENDENT STUDENT’S INCOME INFORMATION TO BE VERIFIED
Have you filed, or were you required to file a Federal Income Tax Return for 2015: Yes No
If you answered YES, check one box:
I have used OR will use the IRS Data Retrieval Tool with my FAFSA to transfer 2015 IRS income tax return information. Log on to your FAFSA, make a correction, navigate to the student financial section and follow the instructions.
I am unable or choose not to use the IRS DRT in FAFSA on the Web, and instead will provide the school a 2015 IRS Tax Return Transcript(s). To obtain a 2015 IRS Tax Return Transcript, go to www.IRS.gov and click on the “Get Transcript of Your Tax Records” link, or call 1-800-908-9946. If you and your spouse filed separate 2015 IRS income tax returns, 2015 IRS Tax Return Transcripts must be provided for both.
If you answered NO, check one box:
I, the student (and if married, student’s spouse) was not employed, did not have income and am not required to file a 2015 Tax Return.
I, the student (and if married, student’s spouse) was employed and had income, but am not required to file a 2015 Tax Return and will list all employer(s) and earnings for 2015 below:
Name of Employer / Amount Earned in 2015 / 2015 W-2 Form Received from Employer? / 2015 W-2 Form Attached to this Form?$ / Yes No / Yes No
$ / Yes No / Yes No
C. INDEPENDENT STUDENT’S FAMILY INFORMATION
List below the people in your household. Include:
· Yourself
· Your spouse, if you are married
· Your children, if any, if you will provide more than half of their support from 7/1/17 through 6/30/18
· Other people only if they live with you, and you provide more than half of their financial support and will continue to do so from 7/1/17 through 6/30/18.
*Include the name of the college for any household member who will be enrolled, at least half-time, in a degree, diploma, or certificate program between 7/1/17 through 6/30/18.
Full Name / Age / Relationship / Name of College / *Undergrad./Graduate / Half-time/
Full-time / Expected
Grad. Date
Self / Muhlenberg / Undergrad.
Relationship Options: student, student’s spouse, student’s child, parent/step-parent, brother/sister, other
· Did you or anyone in your family listed above receive benefits from the Supplemental Nutrition Assistance Program (SNAP) in 2014 or 2015? YES NO
· Did you pay child support in 2015? YES NO
If YES, complete the chart below. Do not include financial support paid for children who live with you, listed above.
Legal Name of Who Paid Child Support / Legal Name of Parent or Guardian to Whom Support Was Paid / Legal Name of Child for Whom Support Was Paid / Annual (2015) Amount Paid Per Child$
$
$
Certification and Signature
I certify that all of the information reported on this worksheet is complete and correct. Purposely providing false or misleading information could result in fines, imprisonment, or both.
______
Student Signature Spouse Signature (if applicable)
______
Date Date
Verification of Student’s Untaxed Income for 2015
Enter annual amounts for applicable items.
If any item does not apply, enter “N/A” for Not Applicable.
A. Payments to tax-deferred pension and retirement savings
List payments (direct or withheld from earnings) to tax-deferred pension and retirement saving plans (e.g., 401(k) or 403(b) plans), including, but not limited to, amounts reported on W-2 forms in Boxes 12a through 12d with codes D, E, F, G, H, S.
Name of Person Who Made the Payment / Total Amount Paid in 2015B. Child Support Received
List the actual amount of child support received for 2015 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered by not actually paid.
Name of Adult Who Received the Support / Name of Child For Whom Support Was Received / Amount of Child Support Received in 2015C. Housing, food, and other living allowances paid to members of the military, clergy, and others. Include cash payments and/or the cash value of benefits received.
Do not include the value of on-base military housing or the value of a basic military allowance for housing.
Name of Recipient / Type of Benefit Received / Amount of Benefit Received in 2015D. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2015. Include Disability Death Pension, Dependency and Indemnity Compensation (DIC) and/or VA Education al Work-Study Allowances.
Do not include federal veteran’s educational benefits such as: “Montgomery GI Bill, Dependents Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill
Name of Recipient / Type of Veterans Non-education Benefit / Amount of Benefit Received in 2015E. Other Taxed Income
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include untaxed income such as workers’ compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25, RailRoad Retirement Benefits, etc.
Do not include any items reported or excluded in A – D above. In addition, do not include student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social Security benefits, combat pay, benefits from flexible spending arrangements, (e.g., cafeteria plans) , foreign income exclusion, or credit for federal tax on special needs.
Name of Recipient / Type of Other Untaxed Income / Amount of Benefit Received in 2015