Fillable 1718 IND V5 (De Anza College)

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1718 IND V5 (De Anza College)

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FOOTHILL COLLEGE DE ANZA COLLEGE
FINANCIAL AID OFFICE FINANCIAL AID OFFICE
12345 El Monte Rd. 21250 Stevens Creek Blvd.
Los Altos Hills, CA 94022-4599 Cupertino, CA 95014-5793
Page 1 of 5 4/11/17
2017-2018 Independent Verification Worksheet (V5)
Student’s Name: ___________________________________________________________ (Student ID#) SID:___________________
Last First
Preferred Name (if different than above) ___________________________________________________
Last First
Because your FAFSA (Free Application for Federal
Student Aid) was selected for ‘Verification’, we
must verify the tax information reported for you
(and for your spouse if you’re married). If there
are discrepancies, we will make the necessary
corrections to your FAFSA.
Note: If you filed a 2015 U.S. tax return, try to use the IRS Data Retrieval Tool
(IRS DRT) through your FAFSA. If you are unable to use or choose not to use the
IRS DRT, you must attach an IRS Tax Return Transcript. If you did not file taxes,
you must attach a Verification of Non-filing Letter. To get these and other types
of transcripts, you can go to www.irs.gov/individuals/get-transcript or call 1-800-
908-9946. Go to your campus’ Financial Aid webpage for more information.
SECTION A. Tax Information
Important Note: The instructions for this form apply to income earned by you (and by your spouse if you are married). If you are
married, and you and your spouse filed separate IRS income tax returns for 2015 or you had a change in marital status after December
31, 2015, please contact the Financial Aid Office for more information.
Do not submit this form until you have successfully completed the IRS DRT and/or have attached all required documents. If you
need clarification or are unable to obtain the necessary documents, please contact your campus’ Financial Aid Office.
Box 2: Complete this box only if you (and/or your spouse, if you are married) did not file a 2015 Income Tax Return
in any country.
You must attach an IRS Verification of Non-filing Letter for 2015 for the person(s) who did not file.
Check and complete all that apply:
I have attached an IRS Verification of Non-filing Letter for 2015 for the person(s) who did not file.
I (and/or my spouse) was/were not employed and had no 2015 income earned from work (including business income, odd jobs, etc.). If this
applies to only you or your spouse because you were not married in 2015, please indicate which one: Yourself Your Spouse
I (and/or my spouse) was/were employed in 2015 and have listed below the names of all employers, the amount earned
from each employer in 2015, and whether the employer provided a W-2 form.
List every source of income earned in or out of the U.S., even if a W-2 form was not issued; include odd jobs, etc.
You must attach a copy of all W-2 forms issued. If a W-2 form was not issued, please attach an explanation.
Employer’s (source’s) Name
If married, indicate “Self”
or “Spouse”
Amount earned in 2015
IRS W-2 Form
Issued?
If earned outside of the
U.S., which country?
Example:
Sarah’s Bakery
Self
$2,000
No
Canada
If you need more space, please attach a signed separate page with the students name and ID number at the top.
Page 2 of 5 4/11/17
___________________________________________________________________________ _______________________________
Student’s Last Name First Name SID
SECTION B. Family Information
Please list the following people in the chart below:
Yourself
Your spouse if you are married.
Your children only if you will provide more than half of the children’s financial support from
July 1, 2017 through June 30, 2018.
Other people currently living with you only if you currently provide and will continue to provide more than half
of their financial support from July 1, 2017 through June 30, 2018.
Do not include any people who live with you but support themselves with their own income,
even if they share some expenses.
Full Name
Age
Relationship to Applicant
Name of College (if attending half-time or
more during the 2017-18 academic year)
Example:
Susan Jones
30
Self
(name of your primary college)
*NOTE: If you need more space, please attach an additional page with the student’s name and ID number at the top.
Section C. Sign This Worksheet
By signing this worksheet, I certify that all the information reported to qualify for federal student aid is complete
and correct. I understand that, periodically, additional documents and/or information may be requested of me and my
family by the Financial Aid Office.
_______________________________________ _____________________
Student’s Signature Date
FOOTHILL COLLEGE DE ANZA COLLEGE
FINANCIAL AID OFFICE FINANCIAL AID OFFICE
12345 El Monte Rd 21250 Stevens Creek Blvd
Los Altos Hills, CA 94022-4599 Cupertino, CA 95014-5793
Page 3 of 5 4/11/17
Identity and Statement of Educational Purpose
(To Be Signed at the Institution)
The student must appear in person at __________________________________________ to
(Foothill/De Anza College)
verify his or her identity by presenting a valid government-issued photo identification (ID), such as, but not limited to, a
driver’s license, other state-issued ID, or passport. The institution will maintain a copy of the student’s photo ID that is
annotated with the date it was received and the name of the official at the institution authorized to collect the student’s
ID.
In addition, the student must sign, in the presence of the institutional official, the following:
Statement of Educational Purpose
I certify that I _____________________________ am the individual signing this
(Print Student’s Name)
Statement of Educational Purpose and that the federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending
_________________________________________ for 2017-2018.
(Foothill/De Anza College)
_________________________________________ _______________
(Student’s Signature) (Date)
______________________
(Student’s ID Number)
Attention Students:
If you are unable to appear in person at the Financial Aid Office, please complete the next
page of this form instead of this side.
OR
Page 4 of 5 4/11/17
Identity and Statement of Educational Purpose
(To Be Signed With Notary)
If the student is unable to appear in person at __________________________________________
(Foothill/De Anza College)
to verify his or her identity, the student must provide:
(a) A copy of the valid government-issued photo identification (ID) that is acknowledged in the
notary statement below, such as but not limited to a driver’s license, other state-issued ID, or
passport; and
(b) The original notarized Statement of Educational Purpose provided below.
Statement of Educational Purpose
I certify that I _____________________________ am the individual signing this
(Print Student’s Name)
Statement of Educational Purpose and that the federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending
_________________________________________ for 2017-2018.
(Foothill/De Anza College)
_________________________________________ _______________
(Student’s Signature) (Date)
______________________
(Student’s ID Number)
Notary’s Certificate of Acknowledgement
State of ________________________________________________________________________
City/County of ___________________________________________________________________
On_____________________, before me, ____________________________________________,
(Date) (Notary’s name)
personally appeared, ____________________________________________, and provided to me
(Printed name of signer)
on basis of satisfactory evidence of identification __________________________________________
(Type of government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WITNESS my hand and official seal
(seal) ________________________________________
(Notary signature)
My commission expires on _________________________
(Date)
Page 5 of 5 4/11/17
High School Completion Status
Provide one of the following documents to indicate what your high school completion status will be when you begin college:
A copy of the high school diploma.
(Evidence of passing the CASHEE may be required for CA High School graduates.)
A copy of the final official high school transcript that shows the date when the diploma was awarded.
(Evidence of passing the CASHEE may be required for CA High School graduates.)
A copy of the General Educational Development (GED) certificate, an official GED transcript that indicates the student passed the
exam, or a state-authorized high school equivalent certificate, like the California High School Proficiency Examination (CHSPE).
For students who completed secondary education in a foreign country, a copy of the “secondary school leaving certificate” or other
similar document.
An academic transcript that indicates the student successfully completed at least a two-year program that is acceptable for full
credit toward a bachelor’s degree.
If State law requires a homeschooled student to obtain a secondary school completion credential for homeschool (other than a
high school diploma or its recognized equivalent), a copy of that credential.
A student who is "home-schooled" in California by a parent who does not hold a California teacher credential is not eligible to satisfy this
requirement, because that "school" would not meet the exemption definition of a "high school” in California.
If State law does not require a homeschooled student to obtain a secondary school completion credential for homeschool (other
than a high school diploma or its recognized equivalent), a transcript or the equivalent, signed by the student's parent or guardian,
that lists the secondary school courses the student completed and documents the successful completion of a secondary school
education in a homeschool setting.
A student who is unable to obtain the documentation listed above must contact the Financial Aid Office.
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1718 IND V5 (De Anza College)

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Completed 19 July 2020

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