DEPENDENT HOUSEHOLD RESOURCES verification GROUP (V6) VERIFICATION WORKSHEET

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1 RETURN TO: FINANCIAL AID OFFICE P. O. BOX J. R. LYNCH STREET JACKSON, MS OFFICE: FAX: DEPENDENT HOUSEHOLD RESOURCES verification GROUP (V6) VERIFICATION WORKSHEET A. STUDENT S INFORMATION (PLEASE PRINT) (STUDENT S LAST NAME) (STUDENT S FIRST NAME) (STUDENT S J-NUMBER) Your Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that before awarding Federal Student Aid, JSU may ask you to confirm the information reported on your FAFSA. We will compare your FAFSA information with documents requested for verification. You and a parent must complete the verification worksheet, attach required documents and submit them to the Financial Aid Office. If there are differences between your FAFSA data and your financial documents, JSU will send corrections electronically to the Federal Student Aid processor to have your information re-processed. You may contact the Financial Aid Office at if you have questions regarding the verification process. B. STUDENT S FAMILY HOUSEHOLD AND NUMBER IN COLLEGE INFORMATION Yourself. Your parent/s (including stepparent) even if the student doesn t live with the parents. Your parents other children if your parent(s) will provide more than half of their support from July 1, 2014, through June 30, 2015, or if the other children would be required to provide parental information if they were completing a FAFSA for Include children who meet either of these standards even if the children do not live with the parents. 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, Also, include below information about any household member, excluding your parent(s), who will be enrolled at least half time in a degree, diploma, or certificate program at a postsecondary educational institution any time between July 1, 2014 and June 30, If more space is needed, provide a separate sheet that includes the information, the student s name and J-Number at the top of the page. J Full Name Age Relationship to Will Be Enrolled at Student College Least Half-Time Yes/No Self Jackson State University Yes Page 1 of 7

2 C. VERIFICATION OF 2013 INCOME INFORMATION FOR TAX FILERS WITH UNUSUAL CIRCUMSTANCES 1) INDIVUDUALS GRANTED A FILING EXTENSION BY THE IRS - If an individual is required to file a 2013 income tax return and has been granted a filing extension by the IRS, provide the following documents: A copy of IRS Form 4868, Application for Automatic Extension of Time to File U. S. Individual Income Tax Return, that was filed with the IRS for 2013; A copy of the IRS s approval of an extension beyond the automatic six-month extension if the individual requested an additional extension of the filing time for tax year 2013; and A copy of IRS Form W-2 for each source of employment income received for tax year 2013 and, if self-employed, a signed statement certifying the amount of the individual s Adjusted Gross Income (AGI) and the U. S. income tax paid for ) INDIVIDUALS WHO FILED AN AMENDED IRS INCOME TAX RETURN If an individual filed an Amended IRS tax return for 2013 the following must be provided: A signed copy of the original 2013 IRS income tax return filed with the IRS or a 2013 Tax Return Transcript, and A signed copy of the 2013 IRS Form 1040X, Amended U. S. Individual Income Tax Return that was filed with IRS. 3) INDIVIDUALS WHO WERE VICTIMS OF IRS IDENTITY THEFT A victim of IRS identity theft who is not able to obtain a 2013 IRS Tax Return Transcript or use the IRS DRT must contact the IRS at Upon authentication of the tax filer s identity, the IRS will provide, by U. S. Postal Service, a printout of the tax filer s 2013 IRS income tax return information. 4) INDIVIDUALS WHO FILED NON-IRS INCOME TAX RETURNS - An individual filed or will file a 2013 income tax return with Puerto Rico, another U. S. territory (e.g., Guam, American Samoa, the U. S. Virgin Islands, the Northern Marianas Islands), or with a foreign country, must provide a signed copy of that 2013 income tax return(s). D. VERIFICATION OF 2013 INCOME INFORMATION FOR STUDENT TAX FILERS INSTRUCTIONS: Complete this section if the student, filed or will file a 2013 income tax return with the IRS. The best way to verify income is by using the IRS Data Retrieval Tool (IRS DRT) that is part of FAFSA on the Web at FAFSA.gov. 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 Tool to transfer 2013 IRS income tax information into the student s FAFSA. It takes up to 2-3 weeks for 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, contact the JSU Financial Aid Office at Check the box that applies: The student has used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2013 income tax return information into the student s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA. The student s school will use the IRS information that was determined in the verification process. The student has not yet used the IRS Data Retrieval Tool in FAFSA on the Web, but will use the tool to transfer 2013 IRS income tax return information into the student s FAFSA once the 2013 IRS income tax return has been filed. See instructions above for information on how to use the IRS Data Retrieval Tool. The student s school cannot complete the verification process until the IRS information has been transferred into the FAFSA. The student is unable or chooses not to use the IRS Data Retrieval Tool in FAFSA on the Web, and the student will submit to the school a 2013 IRS Tax Return Transcript - not a photocopy of the 1040 income tax return. To obtain a 2013 IRS Tax Return Transcript, go to and click on Order an IRS Tax Return Transcript link and not IRS Tax Account Transcript. Use the Social Security Number (or the IRS individual taxpayer identification number), the date of birth of the first person listed on the 2013 IRS income tax return and the address on file with the IRS (Normally this will be the address used on the 2013 IRS tax return when filed). In most cases, for electronic filers, a 2013 IRS Tax Return Transcript may be requested from IRS within 2-3 weeks after the 2013 IRS income tax return has been accepted by the IRS. Generally, for filers of 2013 paper IRS income tax returns, the 2013 IRS Tax Return Transcript may be requested within 8-11 weeks after the 2013 paper IRS income tax return has been received by IRS. Check the box that applies below: Check here if the student s 2013 IRS Tax Return Transcript(s) is attached to this worksheet. Check here if the student s 2013 IRS Tax Return Transcript will be submitted to the school later. Page 2 of 7

3 J-NUMBER: E. VERIFICATION OF 2013 INCOME FOR STUDENT NON TAX FILERS Complete this section if the student will not file AND is not required to file a 2013 income tax return with the IRS. Check the box that applies below: The student was not employed and had no income earned from work in The student was employed in 2013 and has listed below the names of all the student s employers, the amount earned from each employer in 2013, and whether an IRS W-2 form is attached. Attach copies of all 2013 IRS W-2 forms issued to the student by the employer(s). List every employer even if the employer did not issue an IRS W-2 form. If more space is needed, attach a separate sheet with the student s name and Social Security Number at the top of sheet. EMPLOYER S NAME 2013 AMOUNT EARNED ATTACH IRS W-2 FORM F. VERIFICATION OF 2013 INCOME INFORMATION FOR PARENT(S) TAX FILERS INSTRUCTIONS: Complete this section if the student s parent(s) filed or will file a 2013 income tax return with the IRS. The best way to verify income is by using the IRS Data Retrieval Tool (IRS DRT) that is part of FAFSA on the Web at FAFSA.gov. If the student s parent(s) 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 s parent(s) is eligible to use the IRS Data Retrieval Tool to transfer 2013 IRS income tax information into the student s FAFSA. It takes up to 2-3 weeks for 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 contact the JSU Financial Aid Office at Check the box that applies: The student s parent(s) has used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2013 income tax return information into the student s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA. The student s school will use the IRS information that was determined in the verification process. The student s parent(s) has not yet used the IRS Data Retrieval Tool in FAFSA on the Web, but will use the tool to transfer 2013 IRS income tax return information into the student s FAFSA once the 2013 IRS income tax return has been filed. See instructions above for information on how to use the IRS Data Retrieval Tool. The student s school cannot complete the verification process until the IRS information has been transferred into the FAFSA. The student s parent(s) is unable or chooses not to use the IRS Data Retrieval Tool in FAFSA on the Web at: and the student s parent(s) will submit to the school a 2013 IRS Tax Return Transcript - not a photocopy of the 1040 income tax return. To obtain a 2013 IRS Tax Return Transcript, go to and click on Order an IRS Tax Return Transcript link and not IRS Tax Account Transcript. Use the Social Security Number (or the IRS individual taxpayer identification number), the date of birth of the first person listed on the 2013 IRS income tax return and the address on file with the IRS (Normally this will be the address used on the 2013 IRS tax return when filed). In most cases, for electronic filers, a 2013 IRS Tax Return Transcript may be requested from IRS within 2-3 weeks after the 2013 IRS income tax return has been accepted by the IRS. Generally, for filers of 2013 paper IRS income tax returns, the 2013 IRS Tax Return Transcript may be requested within 8-11 weeks after the 2013 paper IRS income tax return has been received by IRS. Check the box that applies below: Check here if the student s parent(s) 2013 IRS Tax Return Transcript(s) is attached to this worksheet. Check here if the student s parent(s) 2013 IRS Tax Return Transcript will be submitted to the school later. Page 3 of 7

4 G. VERIFICATION OF 2013 INCOME FOR STUDENT S PARENT(S) NON TAX FILERS Complete this section if the student s parent(s) will not file AND are not required to file a 2013 an IRS income tax return with the IRS. NOTE; The Financial Aid Office may require you to provide documentation from the IRS that indicates a 2013 income tax return was not filed with the IRS. Check the box that applies: Neither of the student s parent(s) was employed and had no income earned from work in 2013; One or both of the student s parent(s) was employed in 2013 and has listed below the names of all the student s parent(s) employers, the amount earned from each employer in 2013, and whether an IRS W-2 form is attached. Attach copies of all 2013 IRS W-2 forms issued to the parent by the employer(s). List every employer even if the employer did not issue an IRS W-2 form. If more space is needed, attach a separate sheet with includes the student s name and J-Number at the top of sheet. EMPLOYER S NAME 2013 AMOUNT EARNED ATTACH IRS W-2 FORM H. VERIFICATION OF CHILD SUPPORT PAID Complete this section if one of the parents included in the household in Section B or the student paid child support in List below the names of: The person(s) who paid the child support, The name of the person(s) to whom the child support was paid, The names of the children for whom the child support was paid, and the total annual amount of child support that was paid in 2013 for each child. If more space is needed, provide a separate page that includes the student s name and ID number at the top of page. NAME OF PERSON WHO PAID CHILD SUPPORT NAME OF PERSON WHO CHILD SUPPORT WAS PAID NAME OF CHILD FOR WHOM SUPPORT WAS PAID AMOUNT OF CHILD SUPPORT PAID IN 2013 NOTE: If we have reason to believe that the information regarding child support paid is not accurate, we may require additional documentation, such as: A copy of the separation agreement or divorce decree that shows the amount of child support to be provided; A signed statement from the individual receiving the child support certifying the amount of child support received; or Copies of the child support payment checks, money order receipts, or similar records of electronic payments having been made. Page 4 of 7

5 I. VERIFICATION OF RECEIPT OF SNAP (SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM) BENEFITS Did you, your parent(s) or a member of your parent s household receive SNAP Benefits during 2012 or 2013? Yes No If yes, list the names of individual(s) in your parent s household listed in Section B who received SNAP Benefits (formerly known as the Food Stamp Program) sometime during 2012 and/or For assistance in determining the name of the SNAP program in your state, call FED-AID( ). Attach separate sheet if needed; indicate student s J-Number at top of page. If no, continue to Section I. (1) (2) (3) (5) (6) (7) NOTE: If the Financial Aid Office has reason to believe that the information regarding the receipt of SNAP Benefits is inaccurate, you may be required to submit documentation from the agency that issued those benefits. J. VERIFICATION OF OTHER UNTAXED INCOME FOR ) PAYMENTS TO TAX-DEFERRED PENSION AND RETIREMENT SAVINGS List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings 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, and S. NAME OF PERSON WHO MADE THE PAYMENT TOTAL AMOUNT PAID IN ) CHILD SUPPORT RECEIVED List the actual amount of any child support received in 2013 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid. NAME OF ADULT WHO RECEIVED THE SUPPORT NAME OF CHILD FOR WHOM SUPPORT WAS RECEIVED AMOUNT OF CHILD SUPPORT RECEIVED IN ) 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 TOTAL AMOUNT OF BENEFIT RECEIVED IN 2013 Page 5 of 7

6 _ 4) VETERANS NON-EDUCATION BENEFITS List the total amount of veterans non-education benefits received in Include Disability, Death Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances. Do not include federal veterans 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 ) OTHER UNTAXED 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, Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels. NAME OF RECIPIENT TYPE OF OTHER UNTAXED INCOME AMOUNT OF OTHER UNTAXED INCOME RECEIVED IN ) MONEY RECEIVED OR PAID ON THE STUDENT S BEHALF List any money received or paid on the student s behalf (e.g., payment of student s bills) and not reported elsewhere on this form. Enter the total amount of cash support the student received in Include support from a parent whose information was not reported on the student s FAFSA, but do not include support from a parent whose information was reported. For example, if someone is paying rent, utility bills, etc., for the student or gives cash, gift cards, etc., include the amount of that person's contributions unless the person is the student s parent whose information is reported on the student s FAFSA. Amounts paid on the student s behalf also include any distributions to the student from a 529 plan owned by someone other than the student or the student s parents, such as grandparents, aunts, and uncles of the student. Purpose: e.g., Cash, Rent, Books Amount Received in 2013 Source Page 6 of 7

7 7) ADDITIONAL INFORMATION So that we can fully understand the student s family's financial situation, please provide below information about any other resources, benefits, and other amounts received by the student and any members of the student s household. This may include items that were not required to be reported on the FAFSA or other forms submitted to the financial aid office, and include such things as federal Veterans Education Benefits, military housing, SNAP, TANF, 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 Financial Support Amount of Financial Support Received in 2013 COMMENTS: K. CERTIFICATION AND SIGNATURES Each person signing this worksheet certifies that all of the information reported on it is correct and complete. The student and one parent must sign and date this page. WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. (STUDENT S CONTACT PHONE NUMBER) (STUDENT S ADDRESS) (STUDENT S DATE OF BIRTH) (STUDENT S STREET ADDRESS (INCLUDE APT. NUMBER) (CITY) (STATE) (ZIP CODE) (STUDENT S SIGNATURE) (STUDENT S SOCIAL SECURITY NUMBER) (DATE) (PRINT STUDENT S PARENT NAME) (STUDENT S PARENT SIGNATURE) (DATE) Page 7 of 7