2016–2017 Verification Worksheet
Independent Student
A. Independent Student’s Information
_______________________________ _________________________________ _______________________
Student’s Last Name Student’s First Name Student #
____________________________________________ _________________________________________
Student’s Email Address Student’s Phone Number (include area code)
B. Independent Student’s Family Information
List below the people in your household. Include yourself, your spouse if you are married. Include your children and/or anyone who will receive more
than half of their support from July 1, 2016, through June 30, 2017 from you. Include the name of the college for any household member, 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. Attach a separate page if needed.
Will be Enrolled at
Least Half Time
C. Independent Student’s Income Information to Be Verified
Untaxed Income
I received sources of untaxed income in 2015. (Sources may include payments to tax-deferred pension/retirement
savings, child support received, housing, food, and other living allowances paid to members of the military, clergy, and
others, veterans non-education benefits, workers’ compensation, state disability, Black Lung benefits, untaxed portions of
health savings accounts, railroad retirement benefits, unemployment benefits, general relief, alimony, money received or
paid on the your behalf or any other untaxed income received in 2015. Do not include social security benefits,
Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, TANF, combat pay, benefits
from flexible spending arrangements). I have indicated the source and the amount below.
Sources of Untaxed Income (Student)
Filed a tax return
I used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and successfully transfer my 2015 IRS income
information into the FAFSA. Skip to Section D.
2015 IRS tax return transcript is attached. Please write your name and student number on transcript. Skip to Section D.
Your 2016–2017 application was selected for review in a process called verification. We will compare your application with the information on this worksheet and
with any other required documents. If there are differences, your application 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 Office.
