Fillable 2019-2020 2019-2020 VERIFICATION WORKSHEET V5 - DEPENDENT (Palm Beach State College)

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2019-2020 2019-2020 VERIFICATION WORKSHEET V5 - DEPENDENT (Palm Beach State College)

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2019-2020
Academic Year
2019-2020 VERIFICATION WORKSHEET V5 - DEPENDENT
Your Free Application for Federal Student Aid (FAFSA) was selected for review in a process called “Verification.”
In this process, PBSC will compare information from your 2019-2020 FAFSA with this worksheet and financial
data you must submit. The law requires completion of Verification before awarding and/or disbursing federal aid. If
there are differences between your FAFSA application and your verification documentation, electronic corrections to
your FAFSA may be required.
_______________________________ ____________________________
Last Name First Name M.I. PBSC ID Number
_____________________________ ____________________________
PBSC Email Address Phone Number
Please read carefully. If a Section is incomplete, it may delay the processing of your aid.
1. FAMILY INFORMATION AND HOUSEHOLD SIZE
Full Name
Age
Write the names of the people in your parent(s)’ household in the chart below:
1. Include yourself.
2. Include your parent(s):
• If your parents are divorced, list the parent you lived with the most during the
last 12 months. If you did not live with one parent more than the other, indicate
the parent who provided more than half of your support during the last twelve
months.
• If your parent is remarried, include step-parent.
• If your parents are unmarried but live together, list Parent #1 and Parent #2.
3. Include your parent(s)’ other children, if your parents provide more than half of
their support between July 1, 2019 and June 30, 2020 or if the children would be
required to provide parental information if they were completing a 2019-20 FAFSA.
4. Include other dependents, if they now live with your parent(s) and your parent(s)
will continue to provide more than half of their support through June 30, 2020.
Write the age of each family member in the
chart below.
Relationship
Write the relationship of each family member
to the student in the chart below.
College
Add the name of the college for any
household member (excluding parents) who
will be enrolled in a degree, diploma, or
certificate program at an eligible
postsecondary educational institution at least
half-time any time between July 1, 2019 and
June 30, 2020.
Full Name Age Relationship
College
Self
Palm Beach State College
Parent
*If more space is required, attach a separate page.
PBSC ID Number: ____________________
2. DEPENDENT STUDENT’S INCOME AND TAX INFORMATION - Check one box that applies.
Non-Tax Filers with 2017 earnings are federally required to submit a copy of W-2(s) from each employer with this form.
Name of Employer
Amount
Earned in 2017
2017 W-2 and 1099 Forms
received from employer?
2017 W-2, 1099s and Non-
Filing Letter attached?
$ Yes No Yes
$ Yes No Yes
$ Yes No
Yes
*If more space is required, attach a separate page.
COMPLETE
CHART
ONLY IF
BOX C
ABOVE IS
CHECKED
3. PARENT'S INCOME AND TAX INFORMATION - Check only one box that applies.
Non-Tax Filers with 2017 earnings are federally required to submit a copy of W-2(s) from each employer with this form.
Name of Employer
Amount
Earned in 2017
2017 W-2 and 1099 Forms
received from employer?
2017 W-2, 1099s and Non-
Filing Letter attached?
$ Yes No Yes
$ Yes No Yes
COMPLETE
CHART
ONLY IF
BOX C
ABOVE IS
CHECKED
4. Completion of High School or its Equivalent
Provide one of the following documents that indicate the student’s high school completion status when the
student will begin college in 2019-2020:
• 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 copy of the student’s General Educational Development (GED) certificate or GED transcript.
• 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.
• A homeschooled student must provide a Home Education Affidavit
If the student is unable to obtain the documentation listed above, he or she must contact the
financial aid office.
Check here if you previously provided this documentation to Palm Beach State College.
a.
b.
I filed/will file a 2017 Federal IRS Tax Return, Puerto Rican, or
Foreign Income Tax Return.
I was not employed, did not have income and was not required to file a 2017 Federal IRS Tax Return.
• Submit a 2017 Verification of Non
-Filing Letter. Order a free Verification of Non-Filing Letter at
https://www.irs.gov/Individuals/Get-Transcript or call 1-800-908-9946.
c.
I was employed and had income, but was not required to file a 2017 Federal IRS Tax Return:
• Complete the chart below: list employer(s) (include PBSC) and the amount that was earned i
n 2017.
• Attach copies of
all 2017 W-2 and 1099 Forms.
• Submit a 2017 Verification of Non
-Filing Letter. Order a free Verification of Non-Filing Letter at
https://www.irs.gov/Individuals/Get-Transcript or call 1-800-908-9946.
I us
ed the IRS Data Retrieval Tool
I did not use the IRS Data Retrieval Tool (Please submit signed copies of 2017
Tax Return or 2017 Tax Transcript)
a.
b.
I filed/will file a 2017 Federal IRS Tax Return, Puerto Rican, or Foreign Income Tax Return.
I was
not employed, did not have income and was not required to file a 2017 Federal IRS Tax Return.
• Submit a 2017 Verification of Non-Filing Letter. Order a free Verification of Non-Filing Letter at
https://www.irs.gov/Individuals/Get-Transcript or call 1-800-908-9946.
c.
I was employed and had income, but was not required to file a 2017 Federal IRS Tax Return:
• Complete the chart below: list employer(s) and the amount that was earned in 2017.
• Attach copies of all 2017 W-2 and 1099 Forms.
• Submit a 2017 Verification of Non-Fili
ng Letter. Order a free Verification of Non-Filing Letter at
www.irs.gov. See page 3 for instructions.
I used the IRS Data Retrieval Tool
I did not use the IRS Data Retrieval Tool (Please submit signed copies of
2017
Tax Return or 2017 Tax Transcript)
PBSC ID Number: ____________________
Certification and Signatures
___________________________________
Parent Date
____________________________________
Student Date
Each person signing this form certifies that all information reported is complete
and correct. The student and one parent whose information was
reported on FAFSFA must sign and date.
WARNING: If you purposely give false or misleading information on this
worksheet, you may be fined, be sentenced to jail, or both. All information
provided on this worksheet will be used if it differs from what was entered on
the original FAFSA submitted.
Note: Additional information may be requested upon the review of this form.
Please monitor your Pantherweb for any additional RED FLAGS. Click on
"Document Details" for further explanation.
Identity and Statement of Educational Purpose (To Be Signed at the Institution)
The student must appear in person at Palm Beach State College to verify his or her identity by presenting an
unexpired 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 official at the
institution authorized to receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional official, the Statement of
Educational Purpose provided below.
Statement of Educational Purpose
I certify that I ____________________ am the individual signing this 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 Palm Beach State College for
2019-2020.
____________________
Student’s Signature
____________________
Student’s ID Number
__________________
Date
__________________
F.A. Staff Name
________________
F.A. Staff Signature
_______________
Title
____________
Date
If you are unable to appear in person, see notarized option on the following page.
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PBSC ID Number: _________________
Identity and Statement of Educational Purpose (To Be Signed with Notary)
If the student is unable to appear in person at Palm Beach State College to verify his or her
identity, the student must provide:
• A copy of the unexpired valid government-issued photo identification (ID) that is acknowledged in
the notary statement below, or that is presented to a notary, such as, but not limited to, a driver’s
license, other state-issued ID, or passport; and
• The original notarized Statement of Educational Purpose provided below.The original Statement of
Educational Purpose provided below, which must be notarized. If the notary statement appears on a
separate page than the Statement of Educational Purpose, there must be a clear indication that the
Statement of Educational Purpose was
the document notarized.
Statement of Educational Purpose
I certify that I ________________________________ am the individual signing
this 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 Palm Beach State College for 2019-2020.
______________________ _____________________ __________
Student’s Signature Student’s ID Number Date
Notary’s Certificate of Acknowledgment
State of___________________________________________________
City/County of ___________________________________________________
On _________________________, before me, ________________________
(Date) (Notary's Name)
personally appeared _______________________, and provided to me on basis of
satisfactory evidence of identification _______________________________
(Type of government issues photo ID provided)
to be the above-named person who signed the foregoing instrument. WITNESS
my hand and official seal.
My commission expires on
(Seal) ___________________ ________________
(Notary Signature) (Date)
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2019-2020 2019-2020 VERIFICATION WORKSHEET V5 - DEPENDENT (Palm Beach State College)

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Completed 23 July 2020

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