2020–2021 Verification of Tax Mismatch
We have conflicting information regarding you and/or your parentsmarital status.
Please indicate your status in the space provided below. PLEASE COMPLETE IN INK.
The information you provide will be used to verify, update, or correct the information provided on the FAFSA.
The Financial Aid Office reserves the right to request additional documentation necessary to determine your status.
Student Name ____________________________________________ Student ID _______________________________________________________
Student’s Information
Dependent Independent
A. Student Marital Status (please check the box that applies to you)
I am single, never been married
I am married (please provide marriage certificate)
I am not married; however, my partner and I live in one household
I am married; however, I am separated from my spouse
I am divorced
I am widowed
B. Parents’ Marital Status (if student is dependent)
Date of Marriage _____________________________
Date of Separation ___________________________
Date of Divorce_______________________________
Date Became Widowed ______________________
Parent 1 Name______________________________________ and/or Parent 2 Name ____________________________________________
Please check the box that applies to you.
I am single, never been married
I am married (please provide marriage certificate)
I am not married; however, my partner and I live in one household
I am married; however, I am separated from my spouse
I am divorced
I am widowed
CERTIFICATION: Read carefully before signing.
Date of Marriage _____________________________
Date of Separation ___________________________
Date of Divorce_______________________________
Date Became Widowed ______________________
I hereby certify that all information contained in this document, including supporting documentation is true and complete to the best of
my knowledge. I understand that if I am found to have knowingly or intentionally given false or fraudulent statements and/or
documentation, I may be fined, sentenced to jail, or both.
Student’s Signature _________________________________________________________________________
Parent’s Signature ___________________________________________________________________________
Date _______________________________________
Date _______________________________________
Mitchell Community College Financial Aid Office, 500 West Broad Street, Statesville, NC 28677-5264
Phone (704) 978-5435 Fax (704) 978-1302
MCC-561 Equal Opportunity College Rev. 05/20
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_________________________________________________________________________________________________________________________
Financial Aid Officer Evaluation:
No further documentation is necessary:
Further documentation is necessary; see below
I. Acceptable Documentation to Support Your Marital Separation. Submit ONE of the following:
Filed stamped copy of legal separation papers from the court or other filed stamped pre-divorce documents from
your attorney.
Letter from a social agency (ex. DSS) stating that they are aware of your separation and that according to their
files, you are considered separated for their program.
Letter on business letterhead from a reputable third party (Religious/spiritual leader, marriage counselor, attorney,
employer, landlord, etc.) who can confirm your marital separation in their professional capacity; or
If you are a member of the military or a dependent of military personnel, submit a letter from the Family Services
Office, Unit Chaplain, or Unit S-1 Personnel Office
II. Other Acceptable Documentation To Support Your Marital Separation. Select and submit from TWO of the
items listed below if ONE CANNOT be provided from Section I:
Note: You must provide a separate copy of each item you choose, one in your name and the other in the
name of your spouse.
One copy of your lease/rental/mortgage documents showing that you are maintaining a separate household (one
for you and one for your spouse)
Phone bill (one for you and one for your spouse)
Electric bill (one for you and one for your spouse)
Water bill (one for you and one for your spouse)
Personal property tax statement (one for you and one for your spouse); or
Insurance policy (one for you and one for your spouse)
FINANCIAL AID USE ONLY
Financial Aid Officer______________________________________________________________________ Date _______________________________
MCC-561 Equal Opportunity College Rev. 05/20
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