2020-2021 V4 Verification
Worksheet Independent Student
THIS DOCUMENT CANNOT BE FAXED OR EMAILED
A. Independent 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. Independent Student's Other Information to Be Verified
Check the 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.
Name of person receiving benefits: Total amount received:
No one received SNAP benefits.
Complete this section if you or your spouse, if married, paid child support in 2018. List below the name of the person
who paid the child support, the name of the person to whom the child support was paid, the 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
Example (Marty Jones)
Name of Person to Whom Child
Support was Paid
Example (Chris Smith)
Name of Child for Whom
Support Was Paid
Example (Terry Jones)
Amount of Child
Support Paid in
2018
Example ($6,000)
No one paid child support.
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.
C. Identity 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 addition, the student must sign, in the presence of an IRSC employee, the following:
Statement of Educational Purpose
I certify that I, (Print Student’s Name)
am the individual signing this Statement of 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.
Student’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 (Date) ,
before me, (Notary’s name) ,
personally appeared, (Printed name of signer) ,
and provided to me 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.
WITNESS 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
Spouse'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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