20182019 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, 2018, through June 30, 2019 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, 2018, and
June 30, 2019. 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 2016. (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 your behalf or any other untaxed income received in 2016. 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)
2016 Amount
Filed a tax return
I used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and successfully transfer my 2016 IRS income
information into the FAFSA. Skip to Section D.
2016 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 2016. I did not file 2016 taxes with the IRS and am not
required to file a 2016 income tax return. Attached is the Verification of Non-Filing Letter from the Internal Revenue
Service (IRS).
I was employed in 2016, but am not required to file taxes. Listed below are the names of the employer and the amount
earned. W-2 forms are attached. I did not file 2016 taxes with the IRS and am not required to file a 2016 income tax
Employer’s Name (Student)
2016 Amount Earned
IRS W-2 Attached?
D. Additional Information Other Support Received
E. 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.