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 drivers 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,
(Todays Date) (Notarys 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
Suzys 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
Suzys 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.
$
$
Veterans non-education benets such as disability, Death Pension, or
D
ependenc
y & I
ndemnit
y C
ompensa
tion (DIC
) and/or
V
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. Dont 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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