2020–2021 Verification of Tax Mismatch
We have conflicting information regarding you and/or your parents’ marital 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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