ICC-Financial Assistance Office
1 College Drive
East Peoria, IL 61635-0001
Phone: (309) 694-5311
Fax: (309) 694-5160
email: financialaid@icc.edu
Rev. March 14, 2019
2019-2020 V-4 Dependent Verification Worksheet
Your 2019-2020 Free Application for Federal Student Aid (FAFSA) was selected for a process called “verification.” In
this process, we will compare the information from your application to the information on the form and other
documentation that is submitted. The law states that before awarding Federal Student Aid, we may ask you to confirm the
information you submitted on your FAFSA. If there are differences, we will make the required corrections. If we have
any questions regarding the information you submitted to our office and on the FAFSA, we may ask for additional
information.
You must complete this form in INK and submit it along with
any other required documents to the ICC Financial Assistance Office.
A. Student Information:
___________________________________________
____________________
Student Name (please print)
ICC Student ID #
___________________________________________
____________________
Student Address
Date of Birth
___________________________________________
____________________
City State Zip
Phone Number (include area code)
B. Dependent Student’s Household Information: List the people your parents will support
between July 1, 2019 and June 30, 2020.
YOURSELF, even if you do not live with your parents
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
Self
PARENT(S) (including a stepparent) even if the you do not live with your parents.
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
YOUR PARENTS’ OTHER CHILDREN if your parents will provide more than half of the children’s support from July 1, 2019
through June 30, 2020, or if the other children would be required to provide parental information if they were completing a FAFSA for
20192020. Include children who meet either of these standards, even if a child does not live with your parents. If more space is
needed, provide a separate page with the your name and ID number at the top.
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
OTHER PEOPLE if they now live with your parents and your parents provide more than half of the other person’s support, AND
will continue to provide more than half of that person’s support from July 1, 2019 through June 30, 2020. If more space is needed,
provide a separate page with your name and ID number at the top.
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
(over)
Rev. March 14, 2019
C. Certification and Signatures
Each person signing below certifies that all of the
information reported is complete and correct.
The student and one parent whose information was
reported on the FAFSA must sign and date.
It is the policy of this College that no person, on the basis of race, color, religion, gender, national origin, age, disability,
sexual orientation, or veteran’s status, shall be discriminated against in employment, in educational programs and
activities, or in admission. Inquiries and complaints may be addressed to the Compliance Officer, Diversity Department.
Print Student Name
Student ID Number
Student Signature (Required)
Date
Parent of Dependent Student Signature (Required)
Date
WARNING: If you purposely give false or
misleading information, you may be fined,
sent to prison, or both.
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