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 V1 and V5 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)
Rev. March 14, 2019
__________________________________________
____________________
Student Name (please print)
ICC Student ID#
C. Verification of 2017 Student Income Information
Important Note: The questions below apply to the student.
1. Check the box that applies:
You (student) have used the IRS DRT in FAFSA on the Web to transfer 2017 IRS income tax return information into your
FAFSA.
You (student) have not yet used the IRS DRT in FAFSA on the Web, but will use the tool to transfer 2017 IRS income tax
return information into your FAFSA.
You (student) are unable to use the IRS DRT in FAFSA on the Web, and instead will provide the school with a 2017 IRS
Tax Return Transcript(s). Please refer to the “Verification of 2017 Income Information for Individuals with Unusual
Circumstances” form online at http://icc.edu/admissions/financial-aid/forms/.
IRS Tax Return Transcript provided
IRS Tax Return Transcript will be provided at a later date
You (student) DID NOT FILE a 2017 IRS Tax Return and is not required to file a 2017 IRS Tax Return. Please provide a
2017 non-filing status letter from the IRS dated on or after October 1, 2018 that indicates a 2017 IRS income tax return was
not filed with the IRS. Please refer to the “Verification of 2017 Income Information for Individuals with Unusual
Circumstances” form online at http://icc.edu/admissions/financial-aid/forms/.
Verification of Non-Filing Letter provided
Verification of Non-Filing Letter will be provided at a later date.
2. Check the box that applies: Income Earned from Work
You (student) were not employed and had no income earned from work in 2017.
You (student) were employed in 2017 and have listed below the names of all employers and the amount earned from each
employer in 2017. PLEASE PROVIDE COPIES OF ALL 2017 IRS W-2 FORMS ISSUED TO YOU BY YOUR
EMPLOYERS if you did not use the IRS Data Retrieval Tool on the FAFSA. If you do not have the W-2(s) you can
request an IRS Income and Wage Statement. If more space is needed, provide a separate page with the student’s name
and ID number at the top.
Employer’s Name
Annual Amount Earned in 2017
Total Amount of Income Earned from Work
$
Rev. March 14, 2019
Student Signature
Date
D. Verification of 2017 Parent Income Information
Important Note: The questions below apply to your parent(s). Notify the Financial Assistance office if your parent(s) filed
separate IRS income tax returns for 2017 or had a change in marital status after December 31, 2017.
3. Check the box that applies:
Your parents have used the IRS DRT in FAFSA on the Web to transfer 2017 IRS income tax return information into the
student’s FAFSA.
Your parents have not yet used the IRS DRT in FAFSA on the Web, but will use the tool to transfer 2017 IRS income tax
return information into your FAFSA.
Your parents are unable to use the IRS DRT in FAFSA on the Web, and instead will provide the school with a 2017 IRS Tax
Return Transcript(s). Please refer to the “Verification of 2017 Income Information for Individuals with Unusual
Circumstances” form online at http://icc.edu/admissions/financial-aid/forms/.
IRS Tax Return Transcript provided
IRS Tax Return Transcript will be provided at a later date
Your parents DID NOT FILE a 2017 IRS Tax Return and are not required to file a 2017 IRS Tax Return. Please provide a
2017 non-filing status letter from the IRS dated on or after October 1, 2018 that indicates a 2017 IRS income tax return was
not filed with the IRS. Please refer to the “Verification of 2017 Income Information for Individuals with unusual
Circumstances” form online at http://icc.edu/admissions/financial-aid/forms/.
Verification of Non-Filing Letter provided
Verification of Non-Filing Letter will be provided at a later date.
4. Check the box that applies: Income Earned from Work
Your parents were not employed and had no income earned from work in 2017.
Your parents were employed in 2017 and have listed below the names of all employers and the amount earned from each
employer in 2017. PLEASE PROVIDE COPIES OF ALL 2017 IRS W-2 FORMS ISSUED TO YOUR PARENTS BY
THEIR EMPLOYERS if you did not use the IRS Data Retrieval Tool on the FAFSA. If you do not have the W-2(s)
you can request an IRS Income and Wage Statement. If more space is needed, provide a separate page with your name
and ID number at the top.
Employer’s Name
Annual Amount Earned in 2017
Total Amount of Income Earned From Work
$
Rev. March 14, 2019
E. 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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