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15CV6 3/23/15
Your application was selected for review in a process called “Verification.” When a student file is selected for
verification, the Financial Aid Office must document and validate certain data elements from the FAFSA. The
law says we must ask you for additional information before awarding Federal Aid and Maryland Grants or
Scholarships. If there are differences between your application information and your financial documents, the
Financial Aid Office may need to make corrections electronically and you may receive a corrected Student Aid
Report (SAR).
Instructions: Complete all pages of this verification form and submit it to HCC Student Financial Aid Office as
soon as possible, so that your financial aid won’t be delayed. Please contact us if you need any additional
information to fill out this form.
Student Information
__________________________________________________
Last Name First Name MI
________________________________
HCC ID Number
Household Size and Number in College
Fill in the chart on the next page after making a selection below:
I am a DEPENDENT student. My household will include:
Yourself.
Your parents (including a stepparent) even if you don’t live with your parents.
Your parents’ other children (Siblings) if your parents will provide more than half of the children’s support
from July 1, 2015, through June 30, 2016, or if the other children would be required to provide parental
information if they were completing a FAFSA for 2015–2016. Include children who meet either of these
standards even if the children do not live with the parents.
Other people if they now live with the parents and the parents provide more than half of the other
people’s support and will continue to provide more than half of their support through June 30, 2016.
I am an INDEPENDENT student. My household will include:
Yourself.
Your spouse, if you are married.
Your children or your spouse’s children, if you or your spouse will provide more than half of the
children’s support from July 1, 2015, through June 30, 2016, even if the children do not live with you.
Other people if they now live with you and you or your spouse provides more than half of the other
people’s support and will continue to provide more than half of their support through June 30, 2016.
All address and phone number
corrections should be made on
WebAdvisor.
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
finaid@hagerstowncc.edu
FAX: 301-791-9165
2015-2016
V6 Verification
Worksheet
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both
.
15CV6 3/23/15
Please list the persons living in your household; include yourself on the top line.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
Full Name Age Relationship
Attending College
6 credits or more? **
(example) Martha Jones 24 wife City University
Self
**Number in College: Include below information about any household member, excluding the parents,
who will be enrolled at least half time in a degree, diploma, or certificate program at an eligible
postsecondary educational institution any time between July 1, 2014, and June 30, 2015, include the
name of the college.
Financial Information
Please answer all questions below.
In 2013 or 2014, did anyone in the household receive Supplemental Security Income (SSI)?
In 2013 or 2014, did anyone in the household receive benefits from the Supplemental Nutrition
Assistance Program (SNAP) also known as Food Stamps?
In 2013 or 2014, did anyone in the household receive Free or Reduced Price Lunch?
In 2013 or 2014, did anyone in the household receive TANF (Cash Assistance)?
In 2013 or 2014 did anyone in the household receive WIC (Women and Children Nutrition
Program)?
In 2014 did anyone in the household PAY child support?
If yes – Complete the chart below. Children listed in this chart should not be included in the household.
(If you need more space, attach a separate page.)
Name of the person who
paid Child Support
Name of the child for whom
the support was paid
Age
Name of the person to whom
you paid the support.
Amount paid in
2014
Student/Spouse Parent None
Student/Spouse Parent None
Student/Spouse Parent None
Student/Spouse Parent None
Student/Spouse Parent None
Student/Spouse Parent None
15CV6 3/23/15
In 2014 did anyone in the household RECEIVE child support?
If yes, enter annual amount received in 2014: $________________
Asset Information
Independent Students, enter N/A for Parents (*for help, see notes below):
Student/Spouse
Parent As of today, what was your total current balance of cash, savings, and
checking accounts? Do not include student financial aid.
Enter Zero (0) if none.
Student/Spouse Parent As of today, what was the net worth of your investments, including real
estate (not your home)? See notes on bottom of form.
Enter Zero (0) if none.
Student/Spouse Parent As of today, what was the net worth of your current businesses and/or
family owned businesses and/or investment farms? Do not include a
farm that you live on and operate. See notes on bottom of form.
Enter Zero (0) if none.
*
Notes for Asset Questions
Net worth means current value minus debt. If net worth is negative, enter 0.
Investments include real estate (do not include the home in which you live), rental property (includes a unit within a family home that has its own
entrance, kitchen, and bath rented to someone other than a family member) trust funds, UGMA and UTMA accounts, money market funds, mutual
funds, certificates of deposit, stocks, stock options, bonds, other securities, installment and land sale contracts (including mortgages held),
commodities, etc.
Investments also include qualified educational benefits or education savings accounts (e.g. Coverdell savings accounts, 529 college savings plans
and the refund value of 529 prepaid tuition plans). For a student who does not report parental information, the accounts, owned by the student
(and/or the student’s spouse) are reported as student investments. For a student who must report parental information, the accounts are reported as
parental investments, including all accounts owned by the student and all accounts owned by the parents for any member of the household.
Investments do not include the home you live in, the value of life insurance, retirement plans (401[k] plans, pension funds, annuities, non-education
IRAs, Keogh plans, etc.) or cash, savings and checking accounts already reported as cash. Investments also do not include UGMA and UTMA
accounts for which you are the custodian, but not the owner.
Investment value means the current balance or market value of these investments as of the day you completed the FAFSA. Investment debt means
only those debts that are related to the investments.
Business and/or investment farm value includes the market value of land, buildings, machinery, equipment, inventory, etc. Business and/or
investment farm debt means only those debts for which the business or investment farm was used as collateral.
Business value does not include the value of a small business if your family owns and controls more than 50 percent of the business and the
business has 100 or fewer full-time or full-time equivalent employees. For small business value, your family includes (1) persons directly related to
you, such as a parent, sister or cousin, or (2) persons who are or were related to you by marriage, such as a spouse, stepparent or sister-in-law.
Investment farm value does not include the value of a family farm that you (your spouse and/or your parents) live on and operate.
Untaxed Income information
If the section does not apply to you please enter N/A in the first line.
A. Payments to tax-deferred pension and retirement savings
List any payments (direct 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. Submit a copy of all W2’s received for 2014 to the
Financial Aid Office.
Name of Person Who Made the Payment Total Amount Paid in 2014
$
$
Student/Spouse Parent None
15CV6 3/23/15
B. Housing, 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.
Do not include the value of on-base military housing or the value of a basic military allowance for housing.
Name of Recipient Type of Benefit Received
Amount of Benefit
Received in 2014
$
$
$
C. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2014. Include Disability, Death
Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances.
Do not include federal veterans’ educational benefits such as: Montgomery GI Bill, Dependents Education
Assistance Program, VEAP Benefits or Post-9/11 GI Bill.
Name of Recipient
Type of Veterans
Non-education Benefit
Amount of Benefit
Received in 2014
$
$
$
D. Other untaxed 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, 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 – C 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 Investment Act (WIA)
educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans),
foreign income exclusion, or credit for federal tax on special fuels.
Name of Recipient
Type of Other
Untaxed Income
Amount of Other
Untaxed Income
Received in 2014
$
$
$
F. Money received or paid on the student’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 2013. Include
support from a parent whose information was not reported on the student’s 2014–2015 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 2015–2016 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 2014 Source
$
$
$
$
15CV6 3/23/15
Additional information:
So that we can fully understand the student’s family's financial situation, please provide below 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.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
Name of Recipient
Type of
Financial Support
Amount of Financial
Support Received in 2014
$
$
$
$
$
Comments pertaining to supporting the household size listed:
By signing this form you are certifying that all the information reported on it is
complete and correct.
________________________________________________________________________________
Student Signature Date
________________________________________________________________________________
Parent Signature (Required for Dependent Students) Date
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