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 Independent 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. Independent Student’s Household Information: List the people that you (and your spouse if
you are married) will support between July 1, 2019 and June 30, 2020.
YOURSELF AND, IF MARRIED, YOUR SPOUSE (Do not include spouse if you are divorced, separated, or widowed).
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
Self
YOUR CHILDREN, if you will provide more than half of their support from July 1, 2019 through June 30, 2020. If more space is
needed, attach a separate page, make sure your name and ID is at the top.
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
OTHER PEOPLE ONLY if they now live with you and get more than half of their support from you AND will continue to get this
support from July 1, 2019 through June 30, 2020. If more space is needed, attach a separate page, make sure your name and ID is at
the top.
Name
Age
Relationship
Will be Enrolled at Least Half Time
(Yes or No)
Rev. March 14, 2019
Student Signature
Date
Spouse Signature
Date
C. Verification of 2017 Student and Spouse Income Information
Important Note: The questions below apply to you and your spouse, if you are married. Notify the Financial Assistance
Office you or your spouse filed separate IRS income tax returns for 2017 or had a change in marital status after December
31, 2017.
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 the 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) and/or spouse were not employed and had no income earned from work in 2017.
You (student) and/or spouse 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
D. Certification and Signature
Each person signing below certifies that all of the
information reported is complete and correct.
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 Signature
Student ID Number
Student Signature (Required)
Date
Spouse Signature (Optional)
Date
WARNING: If you purposely give
false or misleading information, you
may be fined, sent to prison, or both.
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