Financial Aid and Scholarships Office 2016-17 Verification Form Independent Student Name Student ID # (required) Your financial aid application for the 2016-2017 academic year has been selected for a process called Verification. Verification is a process required by the Department of Education or California Student Aid Commission (CSAC) that is intended to improve the accuracy of the information submitted on the Free Application for Federal Student Aid (FAFSA) or California Dream Act Application. Please complete this form and provide the requested documentation as soon as possible. At U.C. Berkeley we are verifying your responsibility for the dependents you reported on your student aid application. Deadlines: Please return this form, along with the requested documentation, within three weeks of the date of your email notification to allow time for processing. Please note that U.C. Berkeley s verification review includes a review for institutional funding that is based on different criteria than the review for state funding. This means that institutional grant offers can change significantly once the verification review is completed. Corrections to income reported on the financial aid application may also result in a change to state funding. Release of Information: Due to the federal Family Educational Rights and Privacy Act (FERPA), the Financial Aid and Scholarships Office is not authorized to share information with parents or spouses. If you wish to authorize the release of information to a parent, spouse or other third party, you may grant them access in the Delegate Access section of your Cal Central profile. SECTION A STUDENT INFORMATION Enter your address and contact information. Email addresses and telephone numbers will be used to contact you if more information is needed. Student Name: Email Address: Street Address: Daytime Phone: City, State, Zip: Evening Phone: Page 1 of 6 PLEASE USE BLACK INK
SECTION B FAMILY MEMBERS ATTENDING COLLEGE AT LEAST HALF TIME List the people in your household 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, 2016 and June 30, 2017. If you need more lines, use the explanation section or attach additional pages. If a family member listed is not claimed on your parent(s) tax return, write an explanation below. Include: Yourself. Your spouse, if married. Your children, if any, if you will be providing more than half of their support from July 1, 2016 through June 30, 2017. List other people attending college only if they live with you and you provide more than half of their support and will continue to do so from July 1, 2016 through June 30, 2017. Do not list anyone who is NOT attending college; list them in Section C. Name of Family Member Attending College Date of Birth Mo/ Day/Year Relation-ship to Student Name of College 2016-17 College Grade Level Expected Graduation Month/year 1. / / Self UC Berkeley / 2. / / / 3. / / / 4. / / / Section B Explanation: SECTION C OTHER PEOPLE IN HOUSEHOLD NOT ATTENDING COLLEGE List the people in your household who are NOT attending college. List your spouse here if not listed in Section B. If you need more lines, use the explanation section or attach additional pages. If a family member listed is not claimed on your tax return, write an explanation below. Include children NOT attending college, if you will be providing more than half of their support from July 1, 2016 through June 30, 2017. List other people who live with you if you provide more than half of their support and will continue to do so from July 1, 2016 through June 30, 2017. Do not list anyone who has already been listed in Section B. Name of Family Member Date of Birth Mo/Day/Year Relationship to Student Name of Family Member Date of Birth Mo/Day/Year Relationship to Student 1. / / 4. / / 2. / / 5. / / 3. / / 6. / / Section C Explanation: Page 2 of 6
SECTION D BENEFITS In 2014 or 2015, did anyone in your household receive any of the following benefits? Check all that apply. Please provide supporting documentation of benefits received. Answers marked Yes with no documentation will be changed to No. 1. Supplemental Security Income (SSI) Yes No 2. Cal Fresh/SNAP/Food Stamps Yes No 3. Free or Reduced Price School Lunch Yes No 4. Cal Works/TANF Yes No 5. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) Yes No 6. As of today, are you (or your spouse) a dislocated worker? In general, a person may be considered a dislocated worker if he or she: a) is receiving unemployment benefits due to being laid off (if a person quits work, generally he or she is not considered a dislocated worker, even if the person is receiving benefits) b) has been laid off or received a lay-off notice c) was self-employed but is now unemployed due to economic conditions d) a displaced homemaker who previously provided unpaid services to the family (e.g., a stay-at-home mom/dad) is no longer supported by the spouse, is unemployed or underemployed and is having trouble finding a job or upgrading employment If yes, please provide an explanation as to why you or your spouse meet this criteria. If no explanation is provided, we will change the answer to No. Yes No SECTION E UNTAXED INCOME Please report income received in 2015 from the sources listed below. If you do not have an amount to report, enter zero next to the dollar sign. Child Support received for any of your children. Don t include foster care or adoption payments. Money received or paid on your behalf (e.g. bills) not reported elsewhere on the form. This includes money that you received from a parent or other person whose financial information is not reported on this form. Housing, food, or other living allowances paid to members of the military, clergy, and others. Don t include the value of on-base military housing or the value of a basic military allowance for housing. Veterans non-education benefits, such as Disability, Death pension, or Dependency & Indemnity Compensation. Other untaxed income not reported elsewhere, such as workers compensation, disability benefits, etc. Page 3 of 6
SECTION F ADDITIONAL FINANCIAL INFORMATION 1. Complete this section if either you or your spouse paid child support in 2015 for family members NOT listed in Sections B and C. Attach documentation (e.g., copies of the most recent court order(s), cancelled checks, or a letter signed by the parent to whom the child support was paid). Name of Person who paid child support Name of person to whom child support was paid Name of child for whom support was paid Amount of child support paid in 2015 Annual Amount 2. How much of your 2015 Work-Study Program earnings did you report as part of your Adjusted Gross Income? 3. How much of your 2015 grants, scholarships, fellowships or AmeriCorps award did you report as part of your Adjusted Gross Income? Do not include GSI/GSR appointments. 4. Earnings from work under a cooperative education program offered by a college. 5. Combat pay or special combat pay. Only enter the amount that was taxable and included in your Adjusted Gross Income. Do not include untaxed combat pay. SECTION G ASSET INFORMATION CASH AND INVESTMENT Report all asset values as of the date you filed your 2016-17 financial aid application. Only list the percentage you own of the asset value and debt below. Attach additional pages if necessary. Do not leave any item blank; enter 0 if there is no value to report. CASH, SAVINGS AND CHECKING as of the date you filed your financial aid application Enter the total of your cash, savings and checking accounts. INVESTMENTS foreign or domestic, as of the date you filed your financial aid application Investments include trust funds, money market funds, mutual funds, certificates of deposit (CD), stocks, stock options, bonds other securities, Coverdell savings accounts, 529 college savings plans, commodities, Uniform Transfers to Minors Act (UTMA)/ Uniform Gifts to Minors Act (UGMA) Custodial Accounts, partnerships/s corporations. Do not include the value of life insurance and retirement plans (401k) plans, pension funds, annuities, non-education IRAs, Keogh plans. Attach additional pages if necessary. Total Value of Domestic Investment Assets: Total Value of Foreign Investment Assets: See next page for continued asset information (real estate) Page 4 of 6
SECTION G ASSET INFORMATION REAL ESTATE Report all asset values as of the date you filed your 2016-17 financial aid application. Only list the percentage you own of the asset value and debt below. Attach additional pages if necessary. Do not leave any item blank; enter 0 if there is no value to report. REAL ESTATE Foreign or domestic, as of the date you filed your financial aid application Report real estate, other than your primary residence, that you own such as rental property, land, and second or vacation homes. The value is the market value as of the date you filed the financial aid application. Mortgage balance is how much is owed on the property. Include the value of multi-family dwellings that you own (exclude the portion of a dwelling that is your principal residence). List all properties from IRS Form 1040, Schedule E and all other properties not included on a U.S. tax return, including foreign properties. Attach additional pages if necessary. Address: Market value: Mortgage balance: Address: Market value: Mortgage balance: SECTION H Tax Filing Status Filing Status- please check the appropriate box: I and/or my spouse filed a 2015 U.S. Federal Income Tax Return with my/our legal dependents listed on the tax return. Attach a copy of your 2015 US Federal Income Tax Return together with all schedules, W-2s, 1099s and other attachments. Sign the tax forms even if they were prepared by someone else, or if the returns were filed electronically. If you are married, but did not file your return jointly, attach both 2015 tax returns, schedules and W-2s. All documents should be copied onto 8 ½ x 11 paper before submitting. Forms submitted without tax forms will be considered incomplete and will not be processed. I filed a non IRS income tax return. An individual who filed or will file a 2015 income tax return in Puerto Rico, another U.S. Territory (e.g. Guam, American Samoa, the U.S. Virgin Islands, the Northern Marianas Islands), or in a foreign country must provide: A signed copy of that 2015 income tax return(s); or A transcript obtained from a government of a U.S. territory or commonwealth, or a foreign central government that includes all of the tax filer s income and tax information required to be verified for tax year 2015. Supplemental Foreign Income Information form. This form can be obtained in Cal Central under the Tasks section of My Finances. I certify that neither I, nor my spouse, filed a 2015 U.S. Federal Income Tax Return, nor are we required to file. Neither I, nor my spouse, was employed and we had no income from work in 2015. Report income and resources in Sections E, F, and G of this form. I and/or my spouse earned money from employment in 2015. List below the names of all employers and the amount earned from each employer. Attach copies of all 2015 IRS W-2 forms issued to you and your spouse by the employer(s). List all employers even if they did not issue a W-2 form. Employer Name 2015 Amount Earned Was an IRS W-2 Form Issued? Yes No Contract Earnings: list type (child care, housekeeping, home care assistant, etc.) Yes No 2015 Amount Earned Any tax document issued? Yes No Yes No Page 5 of 6
SECTION I - VERIFICATION OF CUSTODIAL RESPONSIBILITY If you indicated on the FAFSA or Dream Act Application that you have dependent children or other legal dependents, please provide two forms of documentation of custodial responsibility (if not already provided above). Documentation may include the options below. If you do not have dependent children or other legal dependents, please skip this section. I have attached a copy of my 2015 Income Tax Return and/or copies of my W-2 Wage Statements to demonstrate my annual income. Provide a letter from an official at your child s school verifying that you are the custodial parent of record and that your child lives with you. Provide a copy of an apartment lease in your name for calendar year 2015 or 2016 with your dependents listed on the lease. All pages of the lease are required. Provide documentation from a social services agency for 2015. The documentation must list the names of all household members. Attach a copy of the custody agreement or divorce settlement granting custody of your dependent child(ren). All pages of the document are required. Child support received for all children. Provide a copy of the court order, or a letter signed by the other parent confirming the amount provided each year. Note: Report the annual amount received in Section F. Provide documentation from your health care provider confirming current pregnancy and state the expected due date of your child. Other documentation: Provide a signed statement explaining your circumstances and provide a copy of your supporting documentation. Note: Report the amount of untaxed financial support received in 2015, or will receive annually going forward in Section F. SECTION J - CERTIFICATION I certify that all information reported and submitted with this form is complete and correct to the best of my knowledge. I understand that if I purposely give false or misleading information, I may be subject to prosecution, which may result in a fine, jail sentence or both. Student Signature CHECKLIST To avoid delays, use the checklist below before faxing or mailing your documents. If your form is not completed properly, or documentation is missing, we will not be able to award you any financial aid. Please submit this form, along with the requested documentation, to the Financial Aid and Scholarships Office within three weeks of the date of your email notification to allow time for processing. Did you complete the Verification form in black ink and answer all questions? Blanks will cause your form to be considered incomplete and it will not be processed. A zero should be entered if there is no value to report. Did you SIGN the certification in Section I of this form? Date Did you photocopy all documentation onto 8 ½ x 11 paper? Did you attach all documentation as instructed on this form? Did you enter your name and student ID number on each page of documentation? Did you keep a copy of everything for your records? To expedite the processing of this form please upload via Cal Central or fax it to our Financial Aid Forms Fax: 855-895-3690 In-person drop-off: Cal Student Central, 120 Sproul Hall Mailing address: University of California, Berkeley, Financial Aid and Scholarships Office 2nd Floor Sproul Hall, Berkeley, CA 94720-1960 Page 6 of 6