ICC Financial Assistance Office
1 College Drive
East Peoria, IL 61635-
0001
Phone: (309) 694-5
600
Fax: (309) 694-
5160
email:
financialaid@icc.edu
Revised October 4, 2017 Page 1 of 2
2020-2021 V4 DEPENDENT VERIFICATION WORKSHEET
Your 2020-2021 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 person(s) that your parent’s will support July 1, 2020 - June 30, 2021.
YOURSELF even if you do not live with your parents
WILL BE
ENROLLED
AT LEAST
HALF TIME?
NAME AGE RELATIONSHIP COLLEGE
YES NO
PARENT(S) even if you do not live with them. Include stepparent if your parent is married.
WILL BE
ENROLLED
AT LEAST
HALF TIME?
NAME AGE RELATIONSHIP COLLEGE
YES NO
YES
NO
YES NO
YES
NO
YOUR PARENTS’ OTHER CHILDREN if your parents will provide more than half of the children’s support from July 1, 2020
through June 30, 2021, or if the other children would be required to provide parental information if they were completing a
FAFSA for 20202021. 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.
WILL BE
ENROLLED
AT LEAST
HALF TIME?
NAME
AGE
COLLEGE
YES NO
YES NO
YES NO
YES NO
(continued on next page)
self
Illinois Central College
Revised October 4, 2017 Page 2 of 2
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, 2020 through June 30, 2021. If more space is
needed, provide a separate page with your name and ID number at the top.
WILL BE
ENROLLED
AT LEAST
HALF TIME?
NAME
AGE
COLLEGE
YES NO
YES
NO
YES NO
YES
NO
C. Certifications 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.
FEDERAL WARNING: If you purposely give false or misleading information on this form; you may be fined, be sentenced to jail, or both.
Print Student Name
ICC Student ID#
Student Signature (Required)
Date
Parent of Dependent Student Signature (Required)
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.
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signature
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signature
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