2017-2018 INDEPENDENT VERIFICATION WORKSHEET Your 2017 2018 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 Email B. FAMILY/HOUSEHOLD INFORMATION 1. Your Spouse, if you are married. Full Name Age College 2. Your children, if any, if you will provide more than half of their support from July 1, 2017, through June 30, 2018, or if the child would be required to provide your information if they were completing a FAFSA for 2017 2018. Include children who meet either of these standards, even if they do not live with you. Full Name Age Relationship to Student College 3. Other Member(s): People that lived with and received more than half their support from you. They will continue to get more than half their support from July 1, 2017 through June 30, 2018. Please provide a notarized personal statement for each of these household members. Full Name Age Relationship to Student Claimed on Student s 2015 Taxes? (Yes/No) College 1 P a g e
C. STUDENT AND/OR SPOUSE TAX FORMS AND INCOME INFORMATION Student s Income Information to Be Verified (Complete #1 OR #2 below, not both) 1. STUDENT TAX RETURN FILERS Instructions: Complete this section if you filed a 2015 IRS income tax return. 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). 2. STUDENT NON-FILERS. Complete this section if you will not file and were not required to file a 2015 income tax return with the IRS. I was not employed nor had income earned from work in 2015. I was employed in 2015, have listed below the names of all employers, and the amount earned from each employer in 2015. Provide copies of all 2015 IRS W-2 forms issued by your 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) $2,000.00 (example) Yes (example) 2 P a g e
Spouse s Income Information to Be Verified (Complete #3 OR #4 below, not both) 3. SPOUSE TAX RETURN FILERS Important Note: The instructions below apply to your spouse, if you do not have one, skip to Section D. Instructions: Complete this section if your spouse filed a 2015 IRS income tax return. Your spouse used the IRS DRT on FAFSA to transfer 2015 IRS income tax return information. Your spouse was 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). Check here if a 2015 IRS Tax Return Transcript is provided for your spouse. 4. SPOUSE NON-FILERS Important Note: The instructions and certifications below apply to your spouse. Complete this section if your spouse will not file and were not required to file a 2015 income tax return with the IRS. Your spouse was not employed nor had income earned from work in 2015. Your spouse was employed in 2015, has listed below the names of all employers, and the amount earned from each employer in 2015. Provide copies of all 2015 IRS W-2 forms issued by the spouse 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) $2,000.00 (example) Yes (example) 3 P a g e
D. ADDITIONAL INCOME INFORMATION Did you and/or your spouse earn less than $10,000 income in 2015 (combined)? Attach a written explanation signed and dated to this worksheet. Your signed written statement must explain how you were 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. 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 2016. 2. CHILD SUPPORT RECEIVED Check the box below and complete this section if child support was received in 2015. Yes, how much? in 2015 3. CHILD SUPPORT PAID Check the box below and complete this section if you and/or your spouse paid child support in 2015. 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 $6,000.00 4 P a g e
4. PAYMENTS TO A TAX-DEFERRED PENSION AND OR RETIREMENT SAVINGS Type of Benefit Student Spouse From Your 2015 W-2(s) Report the sum of boxes 12a-12d, only codes D, E, F, G, H & S $ $ 5. HOUSING, FOOD AND OTHER LIVING ALLOWANCES ***DO NOT LEAVE BLANK*** 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 2015. Name of Recipient Type of Benefit Received Amount Received in 2015 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 2015. 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 your name and student ID number at the top. Name of Recipient Type of Other Untaxed Income Amount of Other Untaxed 5 P a g e
8. MONEY WAS PAID FOR OR RECEIVED ON BEHALF OF THE STUDENT List any money received for or paid on your behalf (e.g., payment of student's bills). Enter the total amount of cash support received in 2015. Include support from a parent whose information was not reported on 2017-2018 FAFSA. For example, if someone is paying rent, utility bills, etc., or gives cash, gift cards, etc., include the amount of that person's contributions. Amounts paid on your behalf also includes any distributions from a 529 plan owned by someone other than yourself or your parents, such as grandparents, aunts, and uncles. Name of Person Making the Contribution Relationship to the Student Amount of Contribution on the Student s Behalf during 2015 Purpose of the Contribution F. CERTIFICATION By signing this form, each individual certifies that all the information reported to be complete and correct. You 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 Spouse Signature (Optional) Date CCSU Financial Aid Office, 1615 Stanley Street, New Britain, CT 06050 Davidson Hall Room 221 (860) 832-2200 Fax- (860) 832-3330 finaid@ccsu.edu www.ccsu.edu/financialaid 6 P a g e