Page 1 of 5 201 South 1460 East, Room 105, Salt Lake City, tah, 84112-9055 Phone: (801) 581-6211; Fax (801) 585-6350; Email: financialaid@sa.utah.edu Website: financialaid.utah.edu Student Last Name: First Name: Student ID: Phone Number: What you must do to complete verification: 1. Complete Sections A through K and sign the form (student and parent(s)) 2. Submit income information (student and parent(s)) A - HOSEHOLD INFORMATION Include in the household: Yourself and your parent(s) (including stepparent) even if you don t live with your parents, and Your sibling(s)/stepsibling(s), even if they don t live with your parent(s), if (A) Your parent(s) provide more than half of their support from July 1, 2016 through June 30, 2017, or (B) The children would be required to report your parent(s) information on the FAFSA; and Other people, if they now live with your parents and your parent(s) provide more than half of their support, and will continue to provide more than half of their support from July 1, 2016 through June 30, 2017. Include in college (College Attending column below): Yourself, as indicated; Other members of your parents household, if they will attend at least half time in 2016-2017 academic year, and they are in a program that leads to a college degree or certificate. Provide actual or anticipated number of credit hours enrolled. Read all of Section B above to determine who to list in your household below FLL NAMES OF THOSE IN HOSEHOLD DATE OF RELATIONSHIP COLLEGE (Your parent(s) should be listed in the household) BIRTH (Month/Year) TO STDENT (if attending) FALL 16 1. SELF NIVERSITY OF TAH 2. 3. 4. 5. 6. INDICATE # OF HORS ENROLLED SPR SM 17 17 Check here, if there are more than six family members. Attach a list with each family member s name, age, relationship, college (if enrolled), and terms attending. B - SNAP/FOOD STAMP BENEFITS INFORMATION Yes No Did your parent(s) receive food stamps or SNAP (Supplemental Nutrition Assistance Program) benefits at any time during the 2014 or 2015 calendar years? 3/4/2016
Page 2 of 5 C CHILD SPPORT PAID INFORMATION Yes No Please indicate whether one (or both) of the student s parent(s) who is listed in the Household Section in Part A of this worksheet paid child support in 2015. The parent(s) must indicate below: the name of the person who paid the child support, the name of the person who received child support, the name of the child for whom child support was paid, and the total amount of child support that was paid in 2015 for each child. If asked by the school, you may need to provide further documentation of the payment of child support. **Do not include child support paid for children listed in the household on the student s FAFSA application.** Name of Person Who Paid Child Support Name of Person Who Received Child Support Name of Child for Whom Support Was Paid Amount of Child Support Paid in 2015 VERIFICATION OF OTHER NTAXED INCOME FOR 2015 Please answer each question below as it applies to the student and the student s parent(s) whose information is on the FAFSA. If more space is needed, provide a separate page with the student s name and ID number at the top. D - PAYMENTS TO TAX-DEFFERED PENSION AND RETIREMENT SAVINGS List any payments in 2015(paid directly 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 Amount Paid in 2015 E CHILD SPPORT RECEIVED List the actual amount of child support received in 2015 for all children in the household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid. Name of Person Who Received Child Support Name of Child For Whom Support Was Paid Amount of Child Support Received in 2015
Page 3 of 5 F - HOSING, 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 in 2015. Do not include the value of on-base military housing or the value of a basic military allowance for housing. Type of Benefit Received Amount of Benefits Received in 2015 G - VETERANS NON-EDCATION 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 Educational Work-Study allowances. Do not include veteran s educational benefits such as: GI Bill, Dependents Education Assistance Program, VEAP Benefits, VA Vocational Rehab Program, etc. Type of Veterans Non-education Benefit Received Amount of Benefits Received in 2015 H - OTHER NTAXED 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 benefits, 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 Innovation and Opportunity Act (WIOA) educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels. Type of Other ntaxed Income Received Amount of Other ntaxed Income Received in 2015
Page 4 of 5 I MONEY RECEIVED OR PAID ON THE STDENT 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 2015. Include support from a parent whose information was not reported on the student s 2016 2017 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 2016-2017 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 2015 Source J ADDITIONAL INFORMATION Please provide 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. Type of Financial Support Amount of Financial Support Received in 2015
Page 5 of 5 K INCOME INFORMATION Please submit student and parent(s) income by following the directions below: Preferred method: pdate tax information on the FAFSA through the IRS Data Retrieval Tool (DRT) if you have not already done so. Please see the link 7 Easy Steps to Complete the FAFSA on the financial aid website (http://financialaid.utah.edu/) for instructions. Please let us know when it is complete. Second method: If you are ineligible to use the IRS Data Retrieval Tool (DRT) then you may submit a 2015 IRS Tax Return Transcript. To obtain a free 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. Make sure to request the IRS Tax Return Transcript and not the IRS tax account transcript. Choose the option to get transcript online. You will need your Social Security Number, date of birth, and the address listed on your IRS tax return when you filed. You may save a PDF copy and attach it to your Mail or you can fax, mail, or drop it off in person. It takes up to two weeks for IRS income information to be available if you filed your tax return electronically and up to eight weeks if you filed a paper return. If you have problems obtaining an IRS Tax Transcript, please call (800) 829-1040 for assistance. Non-Tax filer: If you and/or your parent(s) were not required to file taxes please submit a copy of the Non-Filer Statement located on our website (http://financialaid.utah.edu/) in the Forms section. Please check the applicable box below of how you will confirm your income information: Parent: I have used the IRS Data Retrieval Tool on the FAFSA to report income information. Date completed: I will use the IRS Data Retrieval Tool on the FAFSA to report income information (You must notify our office when it is complete). I am not eligible to use the IRS Data Retrieval Tool and will use the other means as indicated to document income information. Student: I have used the IRS Data Retrieval Tool on the FAFSA to report income information. Date completed: I will use the IRS Data Retrieval Tool on the FAFSA to report income information (You must notify our office when it is complete). I am not eligible to use the IRS Data Retrieval Tool and will use the other means as indicated to document income information. SIGNATRES: STDENT SIGNATRE: DATE: PARENT SIGNATRE: DATE: You MST sign and date this form. Your signature indicates that all information provided on this form is correct, and any requested documents will be provided to verify the reported amounts. Warning: if you purposely give false or misleading information on this worksheet you may