Fillable 2015 2016 Dependent Student Verification Worksheet Tracking Group 4 (Golden Gate University)

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2015 2016 Dependent Student Verification Worksheet Tracking Group 4 (Golden Gate University)

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2015-2016 Verification W
o
r
ksh
ee
t
Dependent Student - Tracking Group V
4
Your 2015-2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. Before awarding Federal
Student Aid, you must confirm the information you and your parents reported on your FAFSA. We will compare your FAFSA with the information on this
worksheet and with any other required documents. If there are differences, your FAFSA information may need to be corrected. You and at least
one parent must complete and sign this worksheet, attach any required documents, and submit the form and other required documents to the
financial aid office. Additional information maybe required to resolve conflicting information.
A. Dependent Student’s Information
Student’s Last Name
Student’s First Name
MI
Student’s SSN or ID Number
Student’s Date of Birth
City
State
Zip
Student’s Email Address
Student’s Phone Number
Student’s Alternate or Cell Phone Number
Parent’s Other Information to Be Verified
B. Supplemental Nutritional Assistance Program
Check the appropriate box below:
No one included in the household on the FAFSA received SNAP benefits in 2013 or 2014.
One of the persons included in the household on the FAFSA received SNAP benefits in 2013 or 2014.
Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we may require documentation
from the agency that issued the SNAP benefits in 2013 or 2014.
C. Child support paid
Check the appropriate box below:
No child support was paid for individuals outside of the household in 2014.
One (or both) of the student’s parents included in the household and/or the student paid child support in 2014 for a child not included in
the parent(s) household. Provide in the space below the names of the persons who paid the child support, the names of the persons to
whom the child support was paid, the names and ages of the children for whom child support was paid, and the total annual amount of
child support that was paid in 2014 for each child.
If you need more spa
ce, attach a separate page that includes the student’s name and Social Security Number at the top.
Name of Person Who P
aid
Child
Suppo
r
t
Name of Person to W
ho
m
Child Support was P
aid
Name of Child for Whom
Suppo
r
t
Age of Child for
Whom Support Was
Amount of
Child
Suppo
r
t
Joe Jones
Jane Doe
Jake Jones
5
$6,000
Note: If we have reason to believe that the information regarding child support paid is inaccurate, we may require additional documentation, such
as:
• A signed statement from the individual receiving the child support certifying the amount of child support received; or
• Copies of the child support payment checks, money order receipts, or similar records of electronic payment having been made.
D. High School Completion Status
Provide one of the following documents that will indicate the student’s high school completion status when the student begins college in 2015-
Student Name:
Student ID Number:
______________________________ __________________________
2016:
Check the box of the document you will attach to this worksheet:
A copy of the Student’s high school diploma.
A copy of the student’s final official high school transcript that shows the date when the diploma was awarded.
A state certificate or transcript received by a student after the student passed a State-authorized examination (GED test, HiSET, TASC, or other
State-authorized examination) that the State recognizes as the equivalent of a high school diploma.
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.
For a homeschooled student in a state where state law requires the 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.
For a homeschooled student from a state where state law does not require the 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 includes a statement that the student successfully
completed 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.
E. Identity and Statement of Educational Purpose
Section E is ONLY
to be completed in person at the Institution or in front of a Notary.
The student must appear in person at
(Name of Postsecondary Education Institution)
to 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 by the institution with the date it was
received and reviewed and the name of the office at the institution authorized to collect the student’s ID. In addition, the student must sign, in the
presence of the institutional official, the Statement of Education Purpose provided below. If you cannot appear in person to sign this Statement
of Educational Purpose, you will need to provide a copy of your government issued ID and this Statement of Educational Purpose notarized by a
public notary.
Statement of Education Purpose
I certify that I
am the individual signing this Statement of Educational Purpose and that the
Printed Student’s Name
Federal student financial assistance I may receive will only be used for educational purposes and to pay the cost of attending
for 2015-2016.
(Name of Postsecondary Educational Institution)
Student’s Signature
Date
Financial Aid Administrator’s Signature
Date
Notary’s Certificate of Knowledge
State of
City/County of
On
2
Student Name:
Student ID Number:
______________________________ __________________________
before me,
personally appeared,
(Notary’s Name) (printed name of signer)
and proved to me 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
(Notary Signature)
(Date Commission Expires)
(Seal)
F. Certification and Signatures
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. WARNING: If you purposely give
false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
The student and one parent must sign and date.
Student’s Signature
Date
Parent’s Signature
Date
Do not mail this worksheet to the U.S. Department of Education.
Submit
this worksheet to the financial aid administrator at your
school.
You should make a copy of this worksheet for your
records.
3
2015-16 INCOME/EXPENSE CERTIFICATION (GRANT RECIPIENT)
GGU ID LAST NAME FIRST NAME
Note: You will not be able to save this PDF form; however, you may type on the form and print it out.
STUDENT INCOME (AND SPOUSE) 2014 INCOME INFORMATION
Please list all income and cash support that you received from January 2014 through December 2014. Include untaxed
earnings that are not reported on your federal income tax return (if you are required to file). If you are married, you MUST
list your spouse's income information.
SOURCE OF INCOME ANNUAL AMOUNT
WAGES
SPOUSE/PARTNER WAGES
UNTAXED INCOME
BENEFITS PROGRAM
FINANCIAL AID
PERSONAL BILLS PAID ON MY
BEHALF
VETERANS NONEDUCATIONAL
BENEFITS
TOTAL INCOME
STUDENT (AND SPOUSE) 2014 EXPENSE INFORMATION
Please list all of your expenses from January 2014 through December 2014. If you are married, you MUST list your
spouse's expense information.
MONTHLY AMOUNT ANNUAL AMOUNT
RENT/MORTGAGE
UTILITIES
FOOD
TRANSPORTATION
CLOTHING
ENTERTAINMENT
OTHER
TOTAL EXPNESES
I hereby certify that all the above information is true, complete and correct. I understand that by providing false
information, I may lose financial aid eligibility which may result in my owing GGU for whatever costs I may have
already incurred.
_____________________________________________ ___________________________________________
STUDENT SIGNATURE DATE
Golden Gate University Financial Aid Office Last Revision: 02/19/2015
2015-16 INCOME/EXPENSE CERTIFICATION (GRANT RECIPIENT)
Please select the appropriate box for the following questions:
a) Do you have a parent or guardian that was a member of the armed forces and died as a result of military service in
Iraq or Afghanistan after 9/11/2001?
b) Were you less than 24 years of age or enrolled as a student at an institution of higher education at the time of your
parent/guardian's death?
c) Student who is subject to involuntary civil commitment upon completion of a period of incarceration for a forcible
or non-forcible sexual offense is ineligible to receive a Pell Grant.
Does this apply to you?
*Checking this box will make you ineligible to receive Pell or FSEOG Grants per federal regulations
As an eligible Pell Grant and/or FSEOG recipient, per federal regulations you must complete a review process called
"Verification" to receive your award. If you stated in your FAFSA that you have Zero income, reported very little
income to support yourself and/or your dependent(s), or were otherwise unable to complete on Page 1 of this form,
please explain below how you supported yourself and/or your dependent(s) in the past year:
I hereby certify that the information provided in this document is true and correct. I also understand that I may lose
my eligibility if I give false or misleading information.
____________________________ __________________________ _______________________
Student Name Student Signature Date
~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~
To be completed by any person or persons who provided in-kind support to the student:
I hereby certify that the above statement is true and that I have provided in-kind support to the above student:
____________________________ __________________________ _______________________
Name Signature Date
(Please attach a copy of the driver's license or signature ID of person who provided in-kind support)
Golden Gate University Financial Aid Office Last Revision: 02/19/2015
Yes
No
*Decline to Answer
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No
*Decline to Answer
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No
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2015 2016 Dependent Student Verification Worksheet Tracking Group 4 (Golden Gate University)

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Completed 20 July 2020

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