Financial Aid
937.328.6034 | financialaid@clarkstate.edu | 570 East Leel Lane, Springfield, Ohio 45505
2020-2021 Verification Worksheet
V5 – Aggregate Group
Your 2020-2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a
process called verification. Clark State Community College is required to collect the following
information and compare it to the information reported on the FAFSA. If any discrepancies are
found, we will make the corrections to your FAFSA. No federal financial aid will be oered until all
discrepancies have been resolved and the FAFSA has been corrected.
SECTION A: Student Information
Name__________________________________________ Student ID Number_____________________
Address_______________________ _____________________________ ____________ ____________
Street City State Zip
Home Phone_________________________ Work Phone ______________________________________
SECTION B: Family Information
Financial Aid
FAC20VG5
If more space is needed, attach a separate page with the student’s name and student ID at the top.
Dependent Students
List the people in your Parent’s household including:
Independent Students
List the people in your household including:
Yourself and your parent(s), including step-parent Yourself, and your spouse, if you have one
Your parents’ other children, IF your parents will
provide more than half of their support from July 1,
2020 thru June 30, 2021 OR the children would be
required to provide parental information when filing
the FASFA.
Your children, if you will provide more than
half of their support from July 1, 2020 through
June 30, 2021
Other people if they now live with your parents and
your parents provide more than half of their support
and will continue to from July 1, 2020 through June
30, 2021
Other people if they now live with you and
you provide more than half of their support
and will continue to from July 1, 2020 through
June 30, 2021
Full Name Age Relationship to
Student
College Will be Enrolled at
least HALF TIME
(Yes or No)
Self Clark State
Financial Aid
SECTION C: Tax Forms and Income Information (all applicants)
STUDENT Tax Forms and Income Information
Check only one box below
The STUDENT has used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and transfer
2018 IRS income information into the student’s FAFSA.
The STUDENT is unable or chooses not to use the IRS Data Retrieval Tool in FAFSA on the Web,
and will instead provide the school with a 2018 IRS Tax RETURN Transcript(s) or a signed copy
of 2018 federal income tax return and applicable schedule. Tax RETURN transcripts can be
requested from the IRS by calling (800)908-9946 or by using this link:
www.irs.gov/Individuals/Get-Transcript.
Check here if you did not and were not required to file a federal income tax return and
attempted to obtain the IRS Verification of Nonfiling letter but were unable to obtain the letter.
If you did not file and were not required to file a 2018 Federal income tax return, list below all
employer(s) and any income received in 2018 (use W-2 or other earning statements if available)
Sources of Income
Complete only if you did not file taxes
Amount Earned in 2018 W-2 Attached
$
$
$
SPOUSE’S or PARENT’S Tax Forms and Income Information
Check only one box below
The SPOUSE/PARENT has used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and
transfer 2018 IRS income information into the student’s FAFSA.
The SPOUSE/PARENT is unable or chooses not to use the IRS Data Retrieval Tool in FAFSA
on the Web, and will instead provide the school with a 2018 IRS Tax RETURN Transcript(s)
or a signed copy of 2018 federal income tax return and applicable schedule. Tax RETURN
transcripts can be requested from the IRS by calling (800)908-9946 or by using this link:
www.irs.gov/Individuals/Get-Transcript.
Check here if you did not and were not required to file a federal income tax return and
attempted to obtain the IRS Verification of Nonfiling letter but were unable to obtain the letter.
If you (SPOUSE/PARENT) did not file and were not required to file a 2018 Federal income tax return, list
below all employer(s) and any income received in 2018 (use W-2 or other earning statements if available)
Sources of Income
Complete only if you did not file taxes
Amount Earned in 2018 W-2 Attached
$
$
$
Financial Aid
937.328.6034 | financialaid@clarkstate.edu | 570 East Leel Lane, Springfield, Ohio 45505
SECTION D: Highschool Completion Status (Required)
Provide one of the following documents to indicate the student’s high school completion status
when the student begins college in 2020-2021:
A copy of the student’s high school diploma.
For students who completed secondary education in a foreign country, a copy of the “secondary
school leaving certificate” or other similar document.
A copy of the student’s final ocial high school transcript that shows the date of graduation.
A state certificate or transcript received by a student after the student passed a State-authorized
examination that the State recognizes as the equivalent of a high school diploma (GED test,
HiSET, TASC, or other State authorized examination).
An academic transcript that indicates the student successfully completed at least a two-year
program that is acceptable for full credit toward a bachelor’s degree.
For a student who was homeschooled in a state where state law requires the student to obtain a
secondary school completion credential for homeschooling (other than a high school diploma or
its recognized equivalent), a copy of that credential.
For a student who was homeschooled in a state where state law does not require the student
to obtain a secondary school completion credential for homeschooling (other than a high
school diploma or its recognized equivalent), a transcript, or the equivalent, signed by the
student’s parent or guardian, that lists the secondary school courses the student completed and
includes a statement that the student successfully completed a secondary school education in
a homeschool setting. A student who is unable to obtain the documentation listed above must
contact the financial aid oce.
SECTION E: Certification Statement
I certify that all of the information on this form and accompanying documents are true and complete to
the best of my knowledge. Furthermore, I arm that I have not knowingly or intentionally provided any
false or fraudulent documentation.
Student Signature __________________________________________________Date_______________
Parent Signature (if parent information is provided) ______________________Date_______________
Financial Aid
937.328.6034 | financialaid@clarkstate.edu | 570 East Leel Lane, Springfield, Ohio 45505
SECTION F: Identity and Statement of Educational Purpose (Required to be signed at the Financial
Aid Oce)
The student must appear in person at Clark State Community College to verify his or her identity
by presenting an unexpired valid government-issued photo identification (ID), such as, but not
limited to, a driver’s license, other state-issued ID, or
passport. The institution will maintain a copy of the student’s photo ID that is annotated by
the institution with the date it was received and reviewed, and the name of the ocial at the
institution authorized to receive and review the student’s ID.
Statement of Educational Purpose
I certify that I ____________________ am the individual signing this Statement of Educational Purpose
(Print Student’s Name)
and that the Federal student financial assistance I may receive will only be used for educational
purposes and to pay the cost of attending Clark State Community College for 2020-2021.
__________________________________ ___________________ ________________________
(Student’s Signature) (Date) (Student’s ID Number)
OFFICE USE ONLY:
I certify that I have received a valid copy of unexpired identification.
______________________________________ ________________________ ________________
(Print Financial Aid Sta Member Name) (Signature) (Date)
If the student is unable to appear in person at Clark State Community College to verify his or her
identity, the student must provide to the institution:
A copy of the unexpired valid government-issued photo identification (ID) that is acknowledged
in the notary statement below, or that is presented to a notary, such as, but not limited to, a
driver’s license, other state-issued ID, or passport; and
The original Statement of Educational Purpose provided below, which must be notarized. If the
notary statement appears on a separate page than the Statement of Educational Purpose, there
must be a clear indication that the Statement of Educational Purpose was the document notarized.
Notary’s Certificate of Acknowledgement:
State of _________________City/County of _________________________On_____________________,
before me, ____________________________, personally appeared, _________________________and
(Notary’s Name) (Printed name of signer)
proved to me on the basis of satisfactory evidence of identification_________________________ to be
(Type of government-issued photo ID provided)
the above-named person who signed the foregoing instrument.
WITNESS my hand and ocial seal:
_______________________________My commission expires on _______________
(Notary signature) (Date) (Place Seal Here)
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