Fillable 1314DEVER4ElectronicForm Distributed 0001 000

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1314DEVER4ElectronicForm Distributed 0001 000

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DEVER4 1314 DEPENDENT OTHER VERIFICATION FORM (V4)
Your 2013 -2014 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called Verification. The law says before
awarding Federal Student Aid, we may ask you to confirm the information you reported on your FAFSA. To verify that you provided correct information
the financial aid administrator at your school will compare your FAFSA with the information on this worksheet and with any other required documents. If
there are differences, your FAFSA information may need to be corrected. You must complete and sign this worksheet, attach any required documents,
and submit the form and other required documents to the financial aid administrator at your school. Your school may ask for additional information. If you
have questions about verification, contact your financial aid administrator as soon as possible so your financial aid will not be delayed.
A. STUDENT INFORMATION
First Name
Phone Format: XXXXXXXXXX E-mail
SSN Format: XXXXXXXXX
B. NON-TAXABLE INCOME INFORMATION TO BE VERIFIED
If yes, I have listed below the names of the persons to whom the child support was paid, the names of the children for whom the child support was paid
and the total amount of child support paid in 2012 for each child. I also attest that I have not included these children as members of my household size.
(Parents can either include these children as members of the household *or* include the amount of child support paid but may not include these children
as members of the household and also list child support paid.
Name who paid the child support Name who received the support For whom support was paid Yearly amount paid
Did the parent (and, if married, the parent's spouse) pay child support in 2012? (See drop down menu for options)
Did someone in the household receive benefits from the Supplemental Nutrition Assistance Program/SNAP (formerly known as
food stamps) any time during the 2011 or 2012 calendar years? (
See drop down menu for options)
Date of Birth
Last NameMI
Date of Birth
Last NameMIFirst Name
ID # (MUST start with A)
C. CERTIFICATIONS
Electronic Certification Agreement. By providing your full student ID # below and by selecting the "I Accept" button, you consent that all of the
information reported is complete and correct. You further agree that you will submit a Dependent Verification Worksheet Affidavit Signature Form, with
original signatures of BOTH the student and parent, for verification purposes.
WARNING: If you purposely give false or misleading information on the worksheet, you may be
fined, be sentenced to jail, or both.
I Accept
ID # (MUST start with A)
Student's Full Name
To electronically submit this form you MUST use the "SUBMIT" button located at the top of this form.
You MUST have Adobe Reader 9 or higher to submit this form electronically.
If you DO NOT see a submit button in the top right of this form you will need to
To verify your form was properly submitted, allow 48 hours then check your "Financial Aid Status" in your Banner Self Service account.
Student Certification:
You MUST submit a Dependent Verification Worksheet Affidavit Signature Form, with original signatures of BOTH the
student and parent, before your financial aid can be finalized. (http://www.sunyorange.edu/financialaid/forms/docs/1213AFFIDAVITDVF_000.pdf)
Parent Certification:
I Accept
Parent's Full Name
Office Use Only
Submitted Notified N/A
Initials: SNAP
CSP
DAVD
ISEP
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Completed 18 February 2020

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