Fill - Free fillable 2019-2020 Dependent Student Aggregate Verication Worksheet (Kellogg Community College) PDF form

Financial Aid

450 North Avenue • Battle Creek, MI 49017-3397

269-965-4123 • FAX 269-966-4089

www.kellogg.edu/nancial-aid

KELLOGG

COMMUNITY COLLEGE

2019-2020 Dependent Student

Aggregate Verication Worksheet

VD5

READ THIS!

You were selected for VERIFICATION by

the Department of Education. Before

the Financial Aid Oce (FAO) can award

Federal Student Aid, please conrm

the information you and your parents

reported on your 2019-2020 FAFSA. A

Kellogg Community College Financial

Aid Administrator will compare the

information reported on your FAFSA

with the information on this worksheet.

If there are dierences, your FAFSA

information will need to be corrected.

You and at least one parent will need

to complete and sign this worksheet,

attach any required documents, and

submit the form to the FAO. The FAO

may ask for additional information. If

you have questions about verication,

contact the FAO as soon as possible so

that your nancial aid will not be delayed.

OPTION 1. IDENTITY & STATEMENT OF EDUCATIONAL PURPOSE

(to be signed at the institution)

The student must appear in person at

to verify his or her identity by presenting an unexpired valid government-issued

photo identication (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 ocial at the institution authorized to receive and review the

student’s ID.

In addition, the student must sign, in the presence of the institutional ocial, the

Statement of Educational Purpose provided below.

I certify that I, , am the individual

signing this Statement of Education Purpose and that the federal student nancial

assistance I may receive will only be used for education purposes and to pay the

cost of attending Kellogg Community College for 2019-2020.

Student Signature Date

Name of Postsecondary Educational Institution

Student Full Name (Please Print)

APPROVED

Sta Name

Date

OPTION 2. NOTARY’S CERTIFICATE OF ACKNOWLEDGMENT

If you, the student, are not able to appear in person at Kellogg Community College, to verify your identity, you must

complete and submit this Notarized Certicate of Acknowledgment Statement:

State of City/County of

On , before me, , personally appeared,

(Today’s Date) (Notary’s Name) (Signer’s Name)

(Type of ID provided)

and provided to me on basis of satisfactory evidence of identication to be the above named

person who signed the foregoing instrument.

Notary Signature Student Signature

Date Student ID#

My Commission Expires on

(Date)

WITNESS my hand and Ocial Seal:

Part I. STUDENT INFORMATION

Last Name First Name M.I. Student ID#

Street Address (include apt. no.) Social Security #

City State Zip Date of Birth

Home Phone Cell Phone Alternative Phone

Part II. HOUSEHOLD INFORMATION

In the box below list ALL members of your parent(s) household. If you have any questions regarding your household members,

contact the FAO. Your household should include:

• The student

• The parents (including a stepparent) even if the student doesn’t live with the parents. If legal parents are unmarried and living

together, include income and other information for parent 1 and parent 2.

• The parents’ other children if the parents will provide more than half of their support from October 1, 2018, through June 30,

2020, or if the other children would be required to provide parental information if they were completing a FAFSA for 2019-

2020. Include children who meet either of these standards even if the children do not live with the parents.

• Other people if they now live with the parents and the parents provide more than half of their support and will continue to

provide more than half of their support through June 30, 2020.

Full Name Age

Male or Female

M or F Relationship College

*Will be Enrolled at

Least Half Time

(Yes or No)?

Self Kellogg Community College Yes

Parent

* For any household member (excluding parents) who will be enrolled at least half time (6 credits) in a degree or certicate

program at an eligible postsecondary educational institution any time during the academic year. If more space is needed,

provide a separate page with the student’s name and ID number at the top.

NOTE: We may require additional documentation if we have reason to believe that the information regarding the household

members enrolled in eligible postsecondary educational institutions is inaccurate.

DEPENDENT STUDENT AGGREGATE VERIFICATION WORKSHEET VD5 2

Part III. STUDENT INCOME INFORMATION

a. Tax Return Filers — Complete this section if you, the student, has led or will le a 2017 tax return with the IRS. You may

have already used the IRS Data Retrieval Tool (DRT), which is part of your FAFSA. For assistance using the DRT, see instruction

on the last page of this worksheet.

Check the box that applies:

I have led a 2017 Federal IRS Tax Return and have used the DRT through FAFSA

I was UNABLE or chose not to use the DRT through FAFSA, and will submit a signed 1040, 1040A, or 1040EZ IRS Individual

Federal Tax Return or an IRS Tax Return Transcript separately:

Attach your 2017 Federal Tax Return or Tax Return Transcript to this worksheet

Or Submit Federal Tax Return or Tax Return Transcript at a later date

To obtain an IRS Tax Return Transcript, go to https://www.irs.gov/individuals/get-transcript to request an electronic

transcript or to receive it by mail. You can also call 1-800-908-9946. Make sure to request a Tax Return Transcript and

NOT the Account Transcript

I have led an amended tax return (1040X) and will attach to this worksheet or submit at a later date.

b. Tax Return Non-lers — Only Select One option. ALL Non-lers must submit a 2017 “IRS Verication of Non-ling Letter”

— which can be retrieved from the IRS online at http://www.irs.gov/Individuals/Get-Transcript or by mail by submitting an

IRS Form 4506-T, found at www.irs.gov/pub/irs-pdf/f4506t.pdf

I was not employed, did not have any income earned from working during the year of 2017

-OR-

I was employed however, I was not required to le a 2017 Federal IRS Tax Return. If so, complete the box below and

attach the following:

Attach copies of all 2017 W-2’s and/or 1099 forms

Name of Employer Amount Earned in 2017 W-2 Attached? Yes or No

Suzy’s Auto Body Shop (example) $2,000.00 (example) Yes (example)

DEPENDENT STUDENT AGGREGATE VERIFICATION WORKSHEET VD5 3

Part IV. PARENT’S INCOME INFORMATION

a. Tax Return Filers — Complete this section for parents listed as a household member under Part II of this form.

If parent have not already used the IRS Data Retrieval Tool (DRT), which is part of your FAFSA, go to www.FAFSA.

gov. For assistance using the DRT, see instructions on the last page of this worksheet.

Check the box that applies:

I, the parent(s), have led a 2017 Federal IRS Tax Return and have used the DRT through FAFSA

I was UNABLE or chose not to use the DRT through FAFSA, and will submit a signed 1040, 1040A, or 1040EZ IRS

Individual Federal Tax Return or an IRS Tax Return Transcript separately:

Attach your 2017 Federal Tax Return Transcript to this worksheet

Or Submit Federal Tax Return or Tax Return Transcript at a later date

To obtain an IRS Tax Return Transcript, go to https://www.irs.gov/individuals/get-transcript to request an electronic

transcript or to receive it by mail. You can also call 1-800-908-9946. Make sure to request a Tax Return Transcript and

NOT the Account Transcript

I, the parent(s), have led an amended tax return (1040X) and will attach to this worksheet or submit at a later date

b. Tax Return Non-Filers – If parent(s) DID NOT le a 2016 Federal tax return. Only Select ONE option. ALL

Non-lers must submit a 2016 “IRS Verication of Non-ling Letter” which can be retrieved from the IRS online

at http://www.irs.gov/Individuals/Get-Transcript or by mail by submitting an IRS Form 4506-T, found at

www.irs.gov/pub/irs-pdf/f4506t.pdf

Check the box that applies:

I, the parent(s), was not employed and did not earn income from working in 2016.

Complete and submit a Household Resources Verication Worksheet indicating how living expenses in 2016

were met. This form can be found online on the Financial Aid webpage or at the FAO.

I, the parent(s), was employed in 2016 however, I was not required to le a 2016 Federal Tax Return. If so, complete the

box below and attach the following:

Attach copies of all 2016 W-2’s and/or 1099 forms

Name of Employer Amount Earned in 2016 W-2 Attached? Yes or No

Suzy’s Auto Body Shop (example) $2,000.00 (example) Yes (example)

DEPENDENT STUDENT AGGREGATE VERIFICATION WORKSHEET VD5 4

Part V. ADDITIONAL INCOME — Use the table below to report Annual amounts for you and your parents. Be sure to enter zeros

if no funds were received in 2017

Parent’s Amount 2016 Additional Financial Information Student’s Amount

$ Combat pay or special combat pay. Only enter the amount that was taxable

and include in your adjusted gross income. Combat pay is reported on the

W-2 in Box 12, Code Q.

$ Payments to tax-deferred pension and savings plans including, but not limited

to, amounts reported on the W-2 for

ms in Boxes 12a-12d, Codes D, E, F, G, H

and S. DO NOT Include DD

$ Child support received for any of your children. Don’t include foster care or

adoption payments. Provide names of child(s) you received child support for:

Housing, food and other living allowances paid to members of the military,

clergy and others (Including cash payments and cash value of benets.) Don’t

include the value of on-base military housing or the value of a basic

military allowance for housing.

Veteran’s non-education benets such as disability, Death Pension, or

ependenc

y & I

ndemnit

y C

ompensa

tion (DIC

) and/or

A E

ducational

Work-Study allowances.

Other untaxed income not reported from FAFSA items 44a - j or 92a- h, such

as workers’ compensation, disability, etc. Don’t include student aid, EIC,

additional child tax credit, welfare payments, untaxed SS benets, SSI,

WIA educational benets, on-base military housing or a military housing

allowance, combat pay, benets from exible spending arrangements

(e.g. cafeteria plans), foreign income exclusion or credit for federal tax on

special fuels.

Part VI. CERTIFICATION AND SIGNATURE

Each person signing this worksheet ceres

that ALL informaon reported is complete and

correct. The student and one parent must sign

and date.

WARNING: If you purposely give false

or misleading information on this work-

sheet, you may be ned, sentenced to jail,

or both.

Student Signature Date

Parent Signature Date

Updated 2/19

RETURN BY MAIL, EMAIL OR FAX TO:

Kellogg Community College

Financial Aid Oce

450 North Avenue

Battle Creek, MI 49017

Email: naid@kellogg.edu

Phone: (269) 965-4123

FAX #: (269) 966-4089

DEPENDENT STUDENT AGGREGATE VERIFICATION WORKSHEET VD5 5

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