Office of Financial Aid at RiderUniversity

2083 Lawrenceville Road

Lawrenceville, New Jersey 08648

(609) 896-5360

Quality Assurance Independent Verification Document 2010-2011

We are requesting you verify the information reported on your financial aid application. Please follow the instructions carefully and return all requested documentation to the Office of Financial Aid as soon as possible. If you have already provided this office with any of the requested documents, please note it next to the appropriate place on this form. We will not be able to provide financial aid if you fail to complete the verification process. If you have any questions concerning this process, please contact the Office of Financial Aid at (609) 896-5360. Please complete each part in its entirety and print clearly.

PART 1 - Student Information

______

Name (last name, first name, middle initial)Social Security No.

______

AddressPhone (123) 456-7890

______

CityStateZip CodeDate of Birth

PART 2 - Student Status

1. Were you (the student) born before January 1, 1987? YES  NO

2. Are you a veteran of the U.S. Armed Forces or are youcurrently serving on active duty in the U.S. YES NO

Armed Forces for purposes other than training? Answer “no” if you are currently an ROTC

student or a cadet or midshipman at a service academy, or are a National Guard or Reserves enlistee

activated only for training. If YES, attach a copy of VA Form DD214.

3. At the beginning of the 2010-2011 school year, will you be working on a master’s or doctorate program YES NO

(such as an MA, MBA, MD, JD, PhD, EdD, graduate certificate, etc.)?

4. Are you married? YES NO

5. At any time since you turned age 13, were both of your parents deceased?  YES NO

If YES, please attach the death certificate for each parent(or if previously provided, please

note it here.)

6. At any time since you turned 13, were you in foster care or were you a dependent or ward of YES NO

the court? If YES, attach documentation of the court ruling.

7. Do you have legal dependents other than a spouse who live with you and receivemore than half of YES NO

their support from you?If YES, be sure to list your dependents in PART 3.

8. Are you or were you an emancipated minor or in legal guardianship as determined by a court in your YES NO

state of legal residence? If YES, attach documentation of court ruling.

9. At any time on or after July 1, 2009, was it determined that you were an unaccompanied youth who was YES NO

homeless or were self-supporting and at the risk of being homeless? If YES, attach documentation

from a high school or school district homeless liaison;an emergency shelter or transitional housing

program;ora director of a runaway or homeless youth basic center or transitional living program.

If you answered YES to any of the above questions, go to PART 3.

If you answered NO to all of these questions, STOP. You have the wrong document. Please contact the Office of Financial Aid for the Quality Assurance Dependent Verification Document or download it at www.rider.edu/finaid.

PART 3 - Information About Family Members

In the space provided below, list all the people in your household. Be sure to include:

  • yourself, and your spouse if you have one, and
  • your children, if you will provide more than half of their supportbetween July 1, 2010and June 30, 2011, and
  • other people if they now live with you, and you provide more than half of their support and will continue to provide more than half of their support between July 1,2010 and June 30,2011, and
  • the names of the college for any household member who will be attending college at least half time between July 1, 2010 and June 30, 2011, and will be enrolled in a degree, diploma, or certificate program.

If you need more space, attach a separate page. College enrollment is subject to verification.

Name of
Family Member / Relationship
To Student / Age / College
in2010-2011 / Will attend at least half time (6 credits) / Expected Year
of Graduation
John Doe
(Example) / Spouse / 20 / CentralUniv. / Yes / 2014
Self / RiderUniv.

PART 4 - Student Federal Tax Information

Did or will you (or your spouse if you have one) file a federal income tax return for2009? YES NO

(IRS form 1040, 1040A, 1040EZ, or appropriate form from country of residence)

If YES, attach a signed photocopy of your (and your spouse’s) federal tax return, including allpages, supporting schedules and

W-2s. If separate tax returns were filed, attach a signed copy of each return. All tax returns provided to Rider University must have a signature, even if the signature was not required for submission to the Internal Revenue Service (IRS). If you (and/or your spouse) did not keep a copy, request a copy of the actual return from the regional office of the IRS (form 4506) or from your tax preparer.

If NO, list below all your sources and amounts of income (if any) received in 2009 and sign the following statement:

EMPLOYER/SOURCE OF INCOMEAMOUNT RECEIVED

Note: For each employer,

______$______please provide a W-2.

______$______

I certify that I DID NOT, I WILL NOT, and I AM NOT REQUIRED TO file a federal tax return for 2009.

______

Student’s signatureDate

______

Spouse’s signatureDate

PART 5 - Student Federal Work-Study Income for 2009

Did you participate in the Federal Work-Study program during 2009? YES NO

If YES, how much income was earned through the Federal Work-Study program in 2009: $______

PART 6 - Child Support Payments

Did you (and/or your spouse) pay child support for non-custodial children in 2009? YES  NO

List support for children who did not reside with you (or your spouse) but to

whom you (or your spouse) were required to provide monies per a divorce or

separation agreement. These children cannot be listed in PART 3.

If YES, how much?$______

Please list the names and ages of the non-custodial children for whom child support payments were made in 2009:

______

NameAgeNameAge

______

NameAgeNameAge

PART 7 - Untaxed Income for 2009

Did you (and/or your spouse) receive any untaxed income and benefits for 2009? YES NO

If YES, complete the following and provide the appropriate documentation.

All amounts and documentation must be for the entire year of 2009. Do not provide a monthly statement of current benefits.

$______Payments to tax-deferred pensions, retirement and savings plans (paid directly or withheld from earnings).

$______Child support received (total amount). For how many children? ______

$______Housing, food, and other living allowances paid to members of the military, clergy, and others (including cash payments and cash value of benefits)

$______Veterans non-education benefits (such as Disability, Death Pension,Dependency and Indemnity Compensation, etc.)

$______Any other untaxed income and benefits, such asworker’s compensation, disability, etc. Do not include welfare payments, untaxed Social Security benefits, and Supplemental Security Income.

$______Other (please specify): ______

PART 8 – Cash, Savings & Checking Accounts

Complete the following by indicating your (and your spouse’s) total current balance of cash, savings and checking accounts as of today. If zero, please write ‘0’ (do not skip). For this section, do not include any of the investments listed in Part 9.

Student’s balance in cash, savings and checking accounts:Spouse’s balance in cash, savings and checking accounts:

$ ______$ ______

PART 9 – Net Worth of Investments

In the space provided, indicate the net worth of your (and your spouse’s) investments as of today. If none, please write zero (do not skip). Investments include real estate (not primary residence), trust funds, UGMA and UTMA accounts, money market funds, mutual funds, certificates of deposit, stocks, stock options, bonds, other securities, Coverdell savings accounts, 529 college savings and prepaid tuition plans, installment and land sale contracts including mortgages held, commodities, etc. Do not include the value of your primary

residence (home) except for any rental portion that is not owner occupied. Do not include the value of life insurance or retirement plans (pension funds, annuities, noneducation IRAs, Keogh plans, etc.). Investment value means the current balance or market value of these investments. Investment debt means only those debts directly related to the investments. If there were significant changes in investment values over what was reported on the FAFSA, please provide an explanation and supporting documents. Attach additional page(s) if necessary.

Student’s Value/DebtSpouse’s Value/Debt

Investment 1:______Investment 1:______

Value $ ______Debt $ ______Value $ ______Debt $ ______

Investment 2:______Investment 2:______

Value $ ______Debt $ ______Value $ ______Debt $ ______

PART 10 – Current Businesses

Do you (and/or your spouse) own a business with more than 100 full-time (or full-time equivalent) employees?  YES  NO

If YES, provide information below for each business, and attach the respective 2009 business tax return and balance sheet (Form 1065, 1120, or 1120S). Business value includes the value of the land, buildings, machinery, equipment and inventory. Business debt means only those debts for which the business was used as collateral. Attach additional page(s) if necessary.

If NO, you do not have to provide business information. Skip to Part 11.

Student’sValue/DebtSpouse’sValue/Debt

Business 1: ______Business 1: ______

Value $ ______Debt $ ______Value $ ______Debt $ ______

Business 2: ______Business 2: ______

Value $ ______Debt $ ______Value $ ______Debt $ ______

PART 11 – Certification

Please check this form for accuracy and completeness. This form will be returned if incomplete and/or if documents are missing.

WARNING:IF YOU PURPOSELY GIVE FALSE OR MISLEADING INFORMATION ON THIS

FORM, YOU MAY BE FINED, SENTENCED TO JAIL, OR BOTH.

By signing this form, we certify that all the information reported on it is complete and correct.

______

Student’s signature Date

______

Spouse’s signature Date

Did you remember to. . .

  • Complete all items?
  • Include a signed copy of the federal tax return(s) with all pages, supporting schedules and W-2s?
  • Provide all other required documentation?
  • Sign the document? 2010-11Indep Verif Doc 02/17/10