20162017 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.
Full Name
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)
2015 Amount
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.
Did not file a tax return
I was not employed and had no income earned from work in 2015.
I was employed in 2015, but am not required to file taxes. Listed below are the names of the employer and the amount
earned. W-2 forms are attached.
Employer’s Name (Student)
2015 Amount Earned
IRS W-2 Attached?
D. Additional Information Other Support Received
E. Independent Student’s Other Information to Be Verified
Check the box below if someone in your household (listed in Section B) received benefits from
the Supplemental Nutrition Assistance Program or SNAP (formerly known as food stamps) any
time during the 2014 or 2015 calendar years.
One of the persons listed in Section B of this worksheet received SNAP benefits in 2014 or 2015.
Check the box below and complete this section if either you or your spouse paid child support in
Either you or if married your spouse listed in Section B of this worksheet paid child support in 2015. I have indicated below
the name of the person who paid the child support, the name of the person to whom the child support was paid, the names
of the children for whom child support was paid, and the total annual amount of child support that was paid in 2015 for each
child. If asked by the school, I will provide documentation of the payment of child support. If you need more space, attach a
separate page that includes the student’s name and Student Number at the top.
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
F. Certification and Signatures
I certify that all of the information reported is complete and correct. The student must sign and
date this worksheet. If married, the spouse’s signature is optional.
_________________________________________________ _________________________________
Student’s Signature Date
_________________________________________________ _________________________________
Spouse’s Signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.