Last Name First Name MI

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1 DEPENDENT VERIFICATION WORKSHEET Your Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says we may ask to confirm the information listed on the FAFSA before awarding Federal Student Aid. The Financial Aid Office at CCSU will compare the information on FAFSA with that of this worksheet and required documents. If there are discrepancies, your FAFSA may need to be corrected, which we will correct and submit for processing. You and at least one parent must complete and sign this worksheet, attach required documents and submit them to our Financial Aid Office. Upon review, we may ask for additional information. Contact us if you have questions. Failure to comply will result in a delay of your financial aid being awarded and/paid. Further delay will result in cancellation. A. STUDENT INFORMATION Last Name First Name MI Address Telephone City/State/Zip B. FAMILY/HOUSEHOLD INFORMATION 1. Your Parent(s): If not married, or living together, list which parent provides more than half of your financial support. If divorced and remarried, list your primary parent as well as step-parent. Full Name Age Relationship to Student Parent 1: (father, mother, stepparent) Parent 2: (father, mother, stepparent) 2. List the people that your parent(s)/stepparent will support between July 1, 2017 and June 30, 2018: Sibling(s): Dependent children under the age of 24 (if your parent(s) provide more than half support, or if they would be required to give parental information when applying for Federal student aid.) Print the name of the college for any sibling attending at least halftime between July 1, 2017 and June 30, 2018 in a degree/certificate program. Full Name Age Relationship to Student College 1 P a g e

2 3. Other Member(s): People that lived with and received more than half their support from your parent(s) at the time you completed the FAFSA. They will continue to get more than half their support from July 1, 2017 through June 30, Please provide a notarized personal statement for each of these household members Full Name Age Relationship to Student Claimed on Parent s 2015 Taxes? (Yes/No) College C. STUDENT & PARENT(S) TAX FORMS AND INCOME INFORMATION Parent s Income Information to Be Verified (Complete #1 OR #2 below, not both) 1. PARENT TAX RETURN FILERS Important Note: The instructions below apply to each parent included in the household. Notify the financial aid office if the parents had a change in marital status after the end of the 2015 tax year (December 31, 2015). Instructions: Complete this section if the parents filed a 2015 IRS income tax return(s). Check the box that applies: Parent(s) utilized the IRS DRT on FAFSA to transfer 2015 IRS income tax return. Parent(s) unable to use the IRS DRT on FAFSA and instead will provide CCSU with a signed 2015 Federal Tax Return (1040, 1040A, or 1040EZ) or 2015 IRS Tax Return Transcript(s). Parents filed separately and will both provide signed 2015 Federal Tax Returns (1040, 1040A, or 1040EZ) or 2015 IRS Tax Return Transcripts. 2 P a g e

3 2. PARENT NON-FILERS Important Note: The instructions and certifications below apply to each parent included in the household. Complete this section if parent(s) will not file and were not required to file a 2015 income tax return with the IRS. Check the box that applies: Parent(s) not employed nor had income earned from work in One or both parents were employed in 2015, have listed below the names of all employers, and the amount earned from each employer in Provide copies of all 2015 IRS W-2 forms issued to the parents by their employers. List every employer even if they did not issue an IRS W-2 form. If more space is needed, provide a separate page with the student s name and ID number at the top. Employer s Name 2015 Amount Earned IRS W-2 Attached? Events Management (example) $2, (example) Yes (example) Student s Income Information to Be Verified (Complete #3 OR #4 below, not both) 3. STUDENT TAX RETURN FILERS Important Note: The instructions below apply to you, the student. Instructions: Complete this section if you filed a 2015 IRS income tax return. Check the box that applies: You utilized the IRS DRT on FAFSA to transfer 2015 IRS income tax return information. You were unable to use the IRS DRT on FAFSA and instead will provide CCSU with a signed 2015 Federal Tax Return (1040, 1040A, or 1040EZ) or 2015 IRS Tax Return Transcript(s). 3 P a g e

4 4. STUDENT NON-FILERS Important Note: The instructions and certifications below apply to you, the student. Complete this section if you will not file and were not required to file a 2015 income tax return with the IRS. Check the boxes that apply: You were not employed nor had income earned from work in You were employed in 2015, have listed below the names of all employers, and the amount earned from each employer in Provide copies of all 2015 IRS W-2 forms issued by the student s employer(s). List every employer even if they did not issue an IRS W-2 form. If more space is needed, provide a separate page with the student s name and ID number at the top. Employer s Name 2015 Amount Earned IRS W-2 Attached? Events Management (example) $2, (example) Yes (example) D. ADDITIONAL INFORMATION Did your parent(s) earn less than $10,000 income in 2015? Attach a written explanation signed by your parent to this worksheet. Their signed written statement must explain how your family was financially supported. Include all types and amounts of taxable and untaxed income and benefits that were received from any family members or relatives and any support received from private, community, state, or other resources. E. PARENT S ADDITIONAL INFORMATION TO BE VERIFIED 1. SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)/FOOD STAMPS Did any household member listed in section B receive SNAP benefits (Food Stamps) in 2015 and/or 2016? If yes, you must submit a statement from the SNAP agency (ex: Department Social Services) that shows who received SNAP benefits (Food Stamps) in 2015 and/or P a g e

5 2. CHILD SUPPORT RECEIVED Check the box below and complete this section if one of the parents (listed in Section B) received child support in Yes, how much? in CHILD SUPPORT PAID Check the box below and complete this section if one of the parents (listed in Section B) paid child support in Name of Person Who Paid Name of Person to Whom Name of Child for Whom Child s Amount of Child Child Support Child Support Was Paid Support Was Paid Age Support Paid Bruce Wayne (example) Miranda Tate (example) Damian Wayne (example) 5 $6, PAYMENTS TO A TAX-DEFERRED PENSION AND OR RETIREMENT SAVINGS Type of Benefit Student Parent From Your 2015 W-2(s) Report the sum of boxes 12a-12d, only codes D, E, F, G, H & S $ $ ***DO NOT LEAVE BLANK*** 5. HOUSING, FOOD AND OTHER LIVING ALLOWANCES Check the box below and complete this section if housing, food and other living allowances were paid to any family member (listed in section B) who is a member of the military or clergy during Name of Recipient Type of Benefit Received Amount Received in P a g e

6 6. VETERAN S NON-EDUCATIONAL BENEFITS Check the box below and complete this section if veteran s non-education benefits were received by any family member (listed in section B) in Name of Recipient Type of Veterans Non-education Amount of Benefits Received 7. OTHER UNTAXED INCOME List the amount of other untaxed income for 2015 not reported and not excluded elsewhere on this form. Include untaxed income from: Workers' Compensation Disability (Not SSDI) Black Lung Benefits Untaxed portions of health savings accounts (IRS From 1040-Line 25) Railroad Retirement Benefits, etc. If more space is needed, provide a separate page with the student s name and ID number at the top. Name of Recipient Type of Other Untaxed Income Amount of Other Untaxed F. CERTIFICATION By signing this form, each individual certifies that all the information reported to be complete and correct. The student and one parent/stepparent must sign and date. Warning: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Student Signature Date Parent/Stepparent Signature Date CCSU Financial Aid Office, 1615 Stanley Street, New Britain, CT Davidson Hall Room 221 (860) Fax- (860) finaid@ccsu.edu 6 P a g e