Dependent Verif ication Form

Dependent Verif ication Form Financial Aid Services 2017-2018 PART I: STUDENT INFORMATION Name: Last First Middle SPIRE ID: Date of Birth: / / Phone Number: ( ) - Email Address: INSTRUCTIONS: 1. This form will not be processed if any items are left blank or illegible. Answer all applicable questions. 2. Please type or print clearly. 3. Submit all required and relevant documentation with this form by fax, email, or in person. See page 3 for information. 4. If clarification of your situation is necessary, additional information or documentation may be required. Check your SPIRE To Do List. PART II: YOUR PARENTS HOUSEHOLD INFORMATION Instructions: Line 1: List yourself, even if you don t live with your parent(s) Lines 2 & 3: List parent(s)/stepparent(s) Lines 4-10: List your parents other children only if your parents will provide more than half of their support between July 1, 2017 and June 30, 2018. List other people if they now live with your parents and your parents provide and will continue to provide more than half of their support between July 1, 2017 through June 30, 2018. Parent: indicate if you provide more than half of the Full Name of Household Member Age Relationship to Student financial support for this person (check one) Name of college attending for 2017-2018. Must be enrolled at least half time 1. Self -------------- UMASS Amherst 2. Parent 1 --------------- Not applicable 3. Parent 2/Stepparent --------------- Not applicable 4. Yes No 5. Yes No 6. Yes No 7. Yes No 8. Yes No 9. Yes No 10. Yes No If additional space is needed, attach a separate page. PART III: STUDENT AND PARENT 2015 INCOME INFORMATION ANSWER ALL QUESTIONS COMPLETELY STUDENT PARENT(S) Did you file a 2015 Federal Income Tax Return? Yes No Yes No If you answer No to this question you must complete Part IV If you or parent(s) filed a 2015 Federal Income Tax Return you can submit one of the following documents: 2015 tax return transcripts obtained from the IRS or Request your or your parents' 2015 tax return transcripts be sent directly to UMass Amherst Financial Aid Services, complete IRS form 4506- T attached at the end of this verification form and fax or mail to the IRS or 3. Signed copies of filed 2015 tax returns (Forms 1040, 1040A or 1040 EZ). Page 1 of 3

Name: SPIRE ID: Page 2 of 3 PART IV: Complete if you or your parent(s) DID NOT FILE AND WERE NOT REQUIRED TO FILE A 2015 FEDERAL INCOME TAX RETURN ANSWER ALL QUESTIONS COMPLETELY Were you or your parents employed and did you or your parents earn income from work in 2015? STUDENT Yes No PARENT(S) Yes No If you or your parents were employed and/or earned income from work in 2015 complete the information below: List the names of all employers and the amount earned from each employer in 2015, even if the employer did not issue an IRS W-2 form. Submit copies of all 2015 W-2 forms that were issued. Employer s Name: Submit copies of all 2015 W-2 forms. Amount Earned: W-2? Yes No W-2? Yes No W-2? Yes No Submit copies of all 2015 W-2 forms. Amount Earned: W-2? Yes No W-2? Yes No W-2? Yes No Everyone must complete this section PART V: OTHER INCOME RECEIVED IN 2015 ANSWER ALL QUESTIONS COMPLETELY STUDENT PARENT(S) Alimony or spousal support received in 2015 and not reported on tax return: Child Support received in 2015: Money received or paid on your behalf (e.g., bills, rent, tuition) by a third party (e.g. other relatives, friends): Payments to tax-deferred pension and retirement savings plans (paid directly or withheld from earnings), including, but not limited to, amounts reported on W-2 forms in Boxes 12a through 12d, codes D, E, F, G, H and S. Don t include amounts reported in code DD (employer contributions toward employee health benefits). Military, clergy, or other housing, food, or living allowance payment received (including cash payments and cash value of benefits): Amount of veterans non-education benefits, such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances: Other untaxed income- list sources of income (e.g. workers compensation, disability, etc.): Source: Source: GOVERNMENT OR STATE BENEFITS RECEIVED BY YOUR HOUSEHOLD IN 2015 OR 2016 (CHECK YES OR NO) Note: you may be required to submit documentation of receiving benefits from providing agency. Medicaid or Supplemental Social Security Income (SSI) (NOT survivor or Social Security Retirement benefits) YES NO Food Stamps (SNAP- Supplemental Nutrition Assistance Program)... YES NO Temporary Assistance for Needy Families (TANF)... YES NO Special Supplemental Nutrition Program For Women, Infants, and Children (WIC)... YES NO Free or Reduced Price Lunch... YES NO

Name: SPIRE ID: Page 3 of 3 PART VI: CHILD SUPPORT PAID IN 2015? YES NO A. Complete this section if your parent or stepparent PAID child support to another household in 2015. Do not include support paid for people listed on PART II, Parents Household Information. Name of Person Who Paid Child Support Name of Person to Whom Child Support Was Paid Name of Child for Whom Support Was Paid Age of Child Amount Paid in 2015 Note: If we have reason to believe the information regarding child support paid is not accurate, additional documentation may be required, such as: a copy of court document that shows the amount of child support to be provided, a statement from the individual receiving the child support certifying the amount of child support received, copies of the child support payment checks or money order receipts, or documentation from State or Federal Office of Child Support Enforcement. NOTICE: Any financial aid awarded prior to verification is tentative. Financial Aid Services has the right, after reviewing your verification information, to change or cancel your award. Changes in funding, administrative/technical errors, changes in application information, enrollment status or reclassification in residency will affect your financial aid award and may result in a revised financial aid award. PART VII: CERTIFICATION By my signature, I certify that all information submitted with, and written on this application, is complete, accurate, and corrections may be made based on data provided, and that if I purposely give false or misleading information on this worksheet, I may be fined, sentenced to prison, or both. I also certify that any federal or state financial aid funds I may receive will only be used to pay for educational expenses related to my attendance at the University of Massachusetts Amherst for 2017-2018. Please be aware Financial Aid Services is obligated to report financial aid applicants that purposely misreported information or altered documentation to obtain federal funds to the Office of Inspector General for investigation and prosecution. Parent Signature: Student Signature: Date: Document must be signed with a real signature. Digital signatures are not accepted. Fax completed, signed form to: 413-545-1700 or email completed, signed form to: fadocs@finaid.umass.edu (Attachments must be a standard image file, or in one of the following file formats:.doc,.docx,.pdf) I authorize Financial Aid Services to discuss or resolve any verification issues with the following persons: (please print) Name:_ Name:_ Relationship: Tel.#: ( ) - Relationship: Tel.#: ( ) - Email Address: Email Address: FINANCIAL AID SERVICES 243 Whitmore Administration Building Phone: 413-545-0801 Fax: 413-545-1700 Email: finaid@finaid.umass.edu Web: umass.edu/umfa

Instructions to use attached IRS Form 4506-T to request 2015 Tax Return Transcripts from the IRS Financial Aid Services 2017-2018 TAX RETURN FILERS: Use one form per person, per request If you or your parent(s) fi led a 2015 income tax return and cannot use or do not wish to use the get a tax transcript tool at irs.gov, complete Form 4506-T below to request a copy of your or your parent(s) 2015 tax return transcript be sent directly to UMass Amherst Financial Aid Services. Note this form is a fillable PDF that allows you to type the information before printing. 1. Complete lines 1a to 4 - name, social security number, current and previous address 2. On Line 6 Transcript requested, indicate the type of tax return you filed (1040, 1040EZ, 1040A), and check box 6a Return Transcript. 3. Check Signatory attests box 4. Print, sign and date the form, mail to address or fax to number on chart below. Where to mail or fax completed IRS Form 4506-T: If you or your parent(s) live in: Mail Completed Form to: Fax Completed Form to: Alabama, Kentucky, Louisiana, Mississippi, Tennessee, Texas, a foreign country, American Samoa, Puerto Rico, Guam, the Commonwealth of the Northern Mariana Islands, the U.S. Virgin Islands, or A.P.O. or F.P.O. address. Stop 6716 AUSC Austin, TX 73301 855-587-9604 Alaska, Arizona, Arkansas, California, Colorado, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Michigan, Minnesota, Montana, Nebraska, Nevada, New Mexico, North Dakota, Oklahoma, Oregon, South Dakota, Utah, Washington, Wisconsin, Wyoming Stop 37106 Fresno, CA 93888 559-456-7227 Connecticut, Delaware, District of Columbia, Florida, Georgia, Maine, Maryland, Massachusetts, Missouri, New Hampshire, New Jersey, New York, North Carolina, Ohio, Pennsylvania, Rhode Island, South Carolina, Vermont, Virginia, West Virginia Stop 6705 P-6 Kansas City, MO 64999 855-821-0094 Please note after submitting this form, it may take up to10 business days for the IRS to process your request. Check you SPIRE To Do List to confirm receipt of your documents by Financial Aid Services.

Form 4506-T (Rev. September 2015) Department of the Treasury Request for Transcript of Tax Return Do not sign this form unless all applicable lines have been completed. Request may be rejected if the form is incomplete or illegible. For more information about Form 4506-T, visit www.irs.gov/form4506t. OMB No. 1545-1872 Tip. Use Form 4506-T to order a transcript or other return information free of charge. See the product list below. You can quickly request transcripts by using our automated self-help service tools. Please visit us at IRS.gov and click on Get a Tax Transcript... under Tools or call 1-800-908-9946. If you need a copy of your return, use Form 4506, Request for Copy of Tax Return. There is a fee to get a copy of your return. 1a Name shown on tax return. If a joint return, enter the name shown first. 1b First social security number on tax return, individual taxpayer identification number, or employer identification number (see instructions) 2a If a joint return, enter spouse s name shown on tax return. 2b Second social security number or individual taxpayer identification number if joint tax return 3 Current name, address (including apt., room, or suite no.), city, state, and ZIP code (see instructions) 4 Previous address shown on the last return filed if different from line 3 (see instructions) 5 If the transcript or tax information is to be mailed to a third party (such as a mortgage company), enter the third party s name, address, and telephone number. Caution: If the tax transcript is being mailed to a third party, ensure that you have filled in lines 6 through 9 before signing. Sign and date the form once you have filled in these lines. Completing these steps helps to protect your privacy. Once the IRS discloses your tax transcript to the third party listed on line 5, the IRS has no control over what the third party does with the information. If you would like to limit the third party s authority to disclose your transcript information, you can specify this limitation in your written agreement with the third party. 6 Transcript requested. Enter the tax form number here (1040, 1065, 1120, etc.) and check the appropriate box below. Enter only one tax form number per request. a Return Transcript, which includes most of the line items of a tax return as filed with the IRS. A tax return transcript does not reflect changes made to the account after the return is processed. Transcripts are only available for the following returns: Form 1040 series, Form 1065, Form 1120, Form 1120-A, Form 1120-H, Form 1120-L, and Form 1120S. Return transcripts are available for the current year and returns processed during the prior 3 processing years. Most requests will be processed within 10 business days...... b Account Transcript, which contains information on the financial status of the account, such as payments made on the account, penalty assessments, and adjustments made by you or the IRS after the return was filed. Return information is limited to items such as tax liability and estimated tax payments. Account transcripts are available for most returns. Most requests will be processed within 10 business days. c Record of Account, which provides the most detailed information as it is a combination of the Return Transcript and the Account Transcript. Available for current year and 3 prior tax years. Most requests will be processed within 10 business days...... 7 Verification of Nonfiling, which is proof from the IRS that you did not file a return for the year. Current year requests are only available after June 15th. There are no availability restrictions on prior year requests. Most requests will be processed within 10 business days.. 8 Form W-2, Form 1099 series, Form 1098 series, or Form 5498 series transcript. The IRS can provide a transcript that includes data from these information returns. State or local information is not included with the Form W-2 information. The IRS may be able to provide this transcript information for up to 10 years. Information for the current year is generally not available until the year after it is filed with the IRS. For example, W-2 information for 2011, filed in 2012, will likely not be available from the IRS until 2013. If you need W-2 information for retirement purposes, you should contact the Social Security Administration at 1-800-772-1213. Most requests will be processed within 10 business days. Caution: If you need a copy of Form W-2 or Form 1099, you should first contact the payer. To get a copy of the Form W-2 or Form 1099 filed with your return, you must use Form 4506 and request a copy of your return, which includes all attachments. 9 Year or period requested. Enter the ending date of the year or period, using the mm/dd/yyyy format. If you are requesting more than four years or periods, you must attach another Form 4506-T. For requests relating to quarterly tax returns, such as Form 941, you must enter each quarter or tax period separately. / / / / / / / / Caution: Do not sign this form unless all applicable lines have been completed. Signature of taxpayer(s). I declare that I am either the taxpayer whose name is shown on line 1a or 2a, or a person authorized to obtain the tax information requested. If the request applies to a joint return, at least one spouse must sign. If signed by a corporate officer, 1 percent or more shareholder, partner, managing member, guardian, tax matters partner, executor, receiver, administrator, trustee, or party other than the taxpayer, I certify that I have the authority to execute Form 4506-T on behalf of the taxpayer. Note: For transcripts being sent to a third party, this form must be received within 120 days of the signature date. Signatory attests that he/she has read the attestation clause and upon so reading declares that he/she has the authority to sign the Form 4506-T. See instructions. Phone number of taxpayer on line 1a or 2a Sign Here Signature (see instructions) Title (if line 1a above is a corporation, partnership, estate, or trust) Date Spouse s signature For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No. 37667N Form 4506-T (Rev. 9-2015) Date