Fillable 2019-2020 Form #5 Aggregate Verification Group (Berkeley City College)

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2019-2020 Form #5 Aggregate Verification Group (Berkeley City College)

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2019-2020
Form #5 – Aggregate Verification Group
Your Free Application for Federal Student Aid (FAFSA) was selected for review process called “Verification”. In this process we
compare your FAFSA with information on this worksheet and other required documents, such as your 2017 IRS tax information.
If there are differences, the Financial Aid Office will make the necessary changes. The Financial Aid Staff will not make any
financial aid payments to you until all verification and required documentation have been met and the necessary corrections have
been made under the financial aid program regulation (34CFR, part 668).
STUDENT INFORMATION
Last Name (Please Print) First Name M.I. Date of Birth
Peralta Student ID
Last 4-digits of SSN
Telephone Number to best reach you
FAMILY/HOUSEHOLD INFORMATION (Please check one of the boxes below).
Dependent Student: List the people in your parents’ household. Include yourself, your parent(s) (including stepparent) even if you don’t
live with your parents, and other children if (a) your parents will provide more than half of their support between July 1, 2019 and June 30,
2020, or (b) 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. Also include any other people who
now live
with your parent(s) and for whom your parent(s) provide more than half of their support and will continue to provide more than
half of their support
through June 30, 2020.
Independent Student: List the people in your household. Include yourself, your spouse (if married), and children if (a) you will provide
more than half of their support between July 1, 2019 and June 30, 2020, even if the children do not live with you. Include also, any other
people who now live with you and for whom you are providing more than half of their support and will continue to provide more than half
of their
support between July 1, 2019 and June 30, 2020.
Write the names of all household members including yourself. Also write the name of the college for any family member, excluding
your parent(s) (if dependent), who will be attending college at least half-time in a degree, diploma, or certificate program at an
eligible postsecondary educational institution between July 1, 2019 and June 30, 2020. Include the name of the college. If more space
is needed,
attach a separate page with the student’s name and Peralta Student ID# at the top.
Full Name
Age
Relationship to
Student
College Attending
Theodore Cleaver (example)
19
Brother
Yellowstone University
Berkeley City College
2050 Center Street
Berkeley, CA
510.981.2805
College of Alameda
555 Ralph Appezzato Mem.Pkwy
Alameda, CA 94501
510.748.2228
Laney College
900 Fallon Street
Oakland, CA 94607
510.464.3314
Merritt College
12500 Campus Drive
Oakland, CA 94619
510.436.2465
Rev. 3/13/2019
2
STUDENT’S (AND SPOUSE’S, IF MARRIED) INCOME & BENEFITS INFORMATION
Check the appropriate boxe below and provide the requested information and documents:
I/we used the IRS Data Retrieval Too
l to transfer my/our 2017 income information to the FAFSA.
I/we did not (or could not
) transfer my/our 2017 income information to the FAFSA using the IRS Data Retrieval Tool. I/we have
attached a copy of my/our 2017 IRS Tax Return Transcript(s).
I (and, if married, the student’s spouse) was not employed and had
no income earned from work in 2017. I have provided a copy
of my IRS Verification of Non-Filing Letter for 2017 (For independent students only).
I (and, if married, the student’s spouse) have income earned from work and not required to file a 2017
income tax return with
the IRS. I have entered all income information below, listing the names of all employers. I have provided copies of all 2017 IRS
W-2 forms and/or 1099 forms. In addition, I have provided a copy of my IRS Verification of Non-Filing Letter for 2017 (for
independent students only).
Employer’s Name
2017
Amount
Earned
IRS W-2, 1099
Provided?
Acme Auto Body Shop (example) $2,000.00
Yes
PARENTS’ INCOME & BENEFITS INFORMATION (Dependent Students Only)
Check the appropriate box below and provide the requested information and documents:
I/we used the IRS Data Retrieval Tool to
transfer my/our 2017 income information to the FAFSA.
I/we did not (or could not) trans
fer my/our 2017 income information to the FAFSA using the IRS Data Retrieval Tool. I/
we have
attached a copy of my/our 2017 IRS Tax Return Transcript(s).
I was
not employed, had no income earned from work in 2017, and did not and was not
required to file taxes for 2017. I
provided a copy of my IRS Verification of Non-Filing Letter for 2017.
I/we wo
rked but did not and were not required to file a 2017 Federal Income Tax Return. I/we have listed below the
names of all
employers, the amount earned from each employer in 2017, whether an IRS W-2 form or 1099 is provided. I/
we listed every
employer even if the employer did not issue an IRS W-2 or 1099 form. I/we provided copies of all 2017
IRS W-2 forms or 1099’s
issued to me/us and documentation that of the IRS Verification of Non-Filing Letter for 2017.
Employer’s Name
201
7 Amount
Earned
IRS W-2, 1099
Provided?
Acme Auto Body Shop (example) $2,000.00
Yes
Rev. 3/13/2019 KT
STUDENT – HIGH SCHOOL COMPLETION STATUS
Provide one of the following documents that indicate you have, or will have a high school
diploma or GED at the
time you
begin taking classes at Peralta Community College District. Peralta Community College District consists
of the following
colleges: Berkeley City College, College of Alameda, Laney College and Merritt College. Please
check the box indicating the
document you are providing:
Copy of your high school diploma
Copy of your final official high school transcript that shows the date the diploma was awarded
Copy of your General Educational Development (GED) certificate or GED transcript
An academic transcript that indicates that you successfully completed at least a two-year college program
that is acceptable for full credit toward a bachelor’s degree (Please note: this option will take additional
time in completing your verification for the evaluation of your transcripts)
If a State law requires a homeschooled 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 or
a copy of your transcript or equivalent signed by a parent or guardian
I do NOT have a high school diploma or GED
If you are unable to obtain the documentation listed above, please contact the financial aid office. An additional
form and/or alternative documentation may be accepted.
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE (TO BE SIGNED IN PERSON AT
THE CAMPUS FINANCIAL AID OFFICE)
You must appear in person at your home Financial Aid Office within the Peralta Community College District (PCCD) to verify your
identity by presenting a valid go
vernment-issued photo identification ID such as, but not limited to, a driver’s license, other state-
issued ID, or passport (note: Military ID cannot be
accepted). The institution
will maintain a
copy of your photo ID that is
annotated by the institution with the date it was received and reviewed along with the
name of the official at the institution authorized
to collect your 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: (To
Be Signed in the presenc
e of
the Institutional Official)
I certify that I
am the individual signing this Statement
of Educational
Print Name
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 PCCD for the 2019-2020 Award Year.
Student signature
Date
For Office Use Only/Date and Initials
Rev. 3/13/2019
3
IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE
(TO BE SIGNED WITH A NOTARY)
If the student
is unable t
o appear in pe
rson
at
one of
the
Peralta
Community
College
campus
Financial Aid Offices to verify your identity, the
student must provide:
a)
A copy of
the valid government iss
ue
d
pho
to
identification (ID)
that is
acknowledged in
the no
tary
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 (note: Military ID cannot be
accepted); and
b)
The original Statement of
Education Purpo
se
provided
below
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
Print Name
federal student financial assistance I may receive will only be used for educational purposes and to pay the cost of attending Peralta Community College
District for 2019-2020.
Student Signature
Date
Peralta Student ID
Notary’s Certifica
te of Acknowledg
ement
State/of
City/County/
of On
, before me,
,
personally appeared,
, and provided to me on basis of
Printed Name of Signer
satisfactory evidence of identification
Type of government-issued photo ID provided
to be the above-named person who signed the
WITNESS my hand and official seal
:
My commission expires on
Date
CERTIFICATION AND SIGNATURE
By signing below,
I/we c
ertify the information
reported on
this
works
heet is
complete and accurate and authorize the Financial Aid Office to perform
necessary electronic ISIR correction on my behalf. I/we agree to provide proof of any information reported on this form or on my FAFSA. I/we realize that
any false statement or failure to give proof when asked may be cause for denial, reduction, withdrawal, and/or repayment of my financial aid. I/we also
understand if we purposely give false or misleading information I/we may be fined, sentenced to jail or both. If you are an independent and married student, a
spouse signature is optional. If you are a dependent student, one parent must sign below.
Student signature Date Spouse Signature (if married) or Parent Signature (if a dependent student) Date
Rev. 4/4/2019
Date
Notary Name
Notary signature
oregoing instrument.
4
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2019-2020 Form 5 Aggregate Verification Group (Berkeley City College)

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Completed 3 September 2020

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