2020-2021 V4 Verification Worksheet
Dependent Student
THIS DOCUMENT CANNOT BE FAXED OR EMAILED
Your 2020-2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says
that before awarding Federal Student Aid, we may ask you to confirm the information you and your parents reported on your FAFSA. To
verify that you provided correct information the financial aid office at your school will compare your FAFSA with the information on this
worksheet and with any other required documents. If there are differences, your FAFSA information may need to be corrected. You and
at least one parent must complete and sign this worksheet, attach any required documents, and submit the form and other required
documents to the financial aid office at your school. YOUR SCHOOL MAY ASK FOR ADDITIONAL INFORMATION. If you have
questions about verification, contact your financial aid office as soon as possible so that your financial aid will not be delayed.
A. Dependent Student’s Information
_____________
_________________________________________________ ___________________________________
Student’s Last Name Student’s First Name Student’s M.I. Student’s IRSC ID Number
______________________________________________________________ ___________________________________
Student’s Street Address (include apt. no.) Student’s Date of Birth
________________
______________________________________________ ___________________________________
City State Zip Code Student’s Email Address
_____________
_________________________________________________ ___________________________________
Student’s Home Phone Number (include area code) Student’s Alternate or Cell Phone Number
B. Parent’s Other Information to Be Verified
Check t
he box that applies
Someone in the student’s household received benefits from the Supplemental Nutrition Assistance Program or SNAP
(formerly known as food stamps) anytime during the 2017 or 2018 calendar year YOU MAY BE REQUIRED
TO PROVIDE DOCUMENTATION OF SNAP BENEFITS RECEIVED.
Nam
e of person receiving benefits:_________________________________Total amount received:________________
No one received SNAP benefits.
One (or both) of the student’s parents paid child support in 2018. The parent has indicated below the name of the person
who paid the child support, name of the person to whom the child support was paid, names of the children for whom
child support was paid, and the total annual amount of child support that was paid in 2018 for each child. YOU MAY BE
REQUIRED TO PROVIDE DOCUMENTATION OF CHILD SUPPORT PAID. If you need more space, attach a
separate page that includes the student’s name and IRSC ID at the top.
Name of Person Who Paid
Child Support
Name of Person to Whom Child
Support was Paid
Name of Child for Whom
Support Was Paid
Amount of Child
Support Paid in
2018
Marty Jones
Chris Smith (example)
Terry Jones
$6,000.00
No one paid child support.
C. Ident
ity and Statement of Educational Purpose (To Be Signed at the Institution)
The student must appear in person at Indian River State College to verify his or her identity by presenting a valid
government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID, or
passport. The IRSC employee will make a copy of the student’s photo ID that is annotated with the date it was received and
the name of the official at the institution authorized to collect the student’s ID.
In addi
tion, the student must sign, in the presence of an IRSC employee, the following:
Statement of Educational Purpose
I certify that I, _______________________________________________ am the individual signing this Statement
of Print Student’s Name
Educational 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 Indian River State College for 2020-2021.
_________________________________________ _______________
St
udent’s Signature Date
NOTARIZED STATEMENT IS ONLY NECESSARY IF STUDENT CANNOT APPEAR IN PERSON
(copy of Driver’s License, US Passport, or other picture ID must accompany this form if signed by a notary)
Notary’s Certificate of Acknowledgement
State of ________________________________________________________________________
City/County of ___________________________________________________________________
On_____________________, before me, ____________________________________________,
(Date) (Notary’s name)
personally appeared, ____________________________________________, and provided to me
(Printed name of signer)
on basis of satisfactory evidence of identification _______________________________________
(Type of government-issued photo ID provided)
to be the above-named person who signed the foregoing instrument.
WIT
NESS my hand and official seal
(seal) ________________________________________
(Notary signature)
My commission expires on __________________
(date)
D. Certification and Signatures
Each person signing this worksheet certifies that all of the
information reported on it is complete and correct.
The student and one parent must sign and date.
__________
_______________________________________ _________________________________
Student’s Signature Date
__________
_______________________________________ _________________________________
Parent’s Signature Date
Do not mail this worksheet to the U.S. Department of Education.
Submit this worksheet to the financial aid office at your school.
You should make a copy of this worksheet for your records.
WARNING: If you purposely give false or misleading
information on this worksheet, you may be fined, be sentenced
to jail, or both.
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