Fillable 2021-2022 Dependent V5 Worksheet (Eastern Wyoming College)

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2021-2022 Dependent V5 Worksheet (Eastern Wyoming College)

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STUDENT INCOME: See the “Income Verification” section on page two for more information.
Hand deliver or mail original:
Financial Aid Office
Eastern Wyoming College
3200 West C Street
Torrington, WY 82240
2021-2022
Dependent V5 Worksheet
(Aggregate Verification)
Your application has been selected for review in a process called “Verification.” In this process, the information from your Free
Application for Federal Student Aid (FAFSA) will be compared with your and your parent(s)’ Federal IRS tax information. If there are
differences, your FAFSA may need to be corrected. You and at least one parent must complete and sign this worksheet. The Statement
of Educational Purpose must be signed in person with a Financial Aid Office Administrator, EWC Outreach Coordinator, or
Notary Public. This worksheet and all required documents must be hand-delivered or mailed to the Financial Aid Office at EWC.
___________________________________________________________ ____________________ __________________________
Last Name First Name M.I. EWC Student ID Number Social Security Number (last four digits)
___________________________________________________________ _______________________________________________
Mailing Address (include apartment number) E-mail Address
___________________________________________________________ _______________________________________________
City, ST, Zip Phone Number (include area code)
Fill in the information below about the household member(s) your parent(s) will support between July 1, 2021 and June 30, 2022.
INCLUDE YOURSELF, YOUR PARENT(S) (including step-parent), YOUR SIBLINGS, AND ANY OTHERS WHO RECEIVE
MORE THAN HALF OF THEIR SUPPORT FROM YOUR PARENT(S). Include siblings (not parents) who are or will be enrolled in
college at least half time (six credits) and who are also considered dependent for FAFSA purposes. List the name of the college other
household member(s) will be attending if they are or will be enrolled in an eligible degree, diploma, or certificate program at a
school eligible for Title IV funds for at least six credits any time between July 1, 2021 and June 30, 2022.
Full name of household member
Age
Relationship to student
College attending
Self EWC
(Select one option in the list to the right and one option below): I have submitted: OR I plan to submit:
I used the IRS Data Retrieval Tool process to transfer my 2019 IRS income tax return information when completing or updating
my 2021-2022 FAFSA (See “Income Verification” for Instructions).
If you received income earned from the Federal Work-Study Program, need-based employment portions of fellowships and
assistantships, or a cooperative education program offered by a college in 2019, write in the type and amount you included on your 2019
Federal tax return: Type: __________________________________________ $______________
My SIGNED 2019 Federal IRS Tax Return Transcript or SIGNED and FILED 2019 income tax return is attached.
(See “Income Verification” for Instructions).
If you received income earned from the Federal Work-Study Program, need-based employment portions of fellowships and
assistantships, or a cooperative education program offered by a college in 2019, write in the type and amount you included on your
2019 Federal tax return: Type: __________________________________________ $______________
I worked in 2019, but was not required to file a tax return. My 2019 W-2s are attached. My earnings were: $________________.
For more information regarding W-2 Forms and Income (including self-employment), please see the “Income Verification” section.
I was not employed and had no income earned from work in 2019. I was not required to file a tax return.
STUDENT INFORMATION
FAMILY INFORMATION
Over
PARENT(S)’ INCOME: See the “Income Verification” section below for more information.
(Select one option in the list to the right and one option below): My parent(s)… have submitted: OR plan to submit:
My parent(s) used the IRS Data Retrieval process to transfer their 2019 IRS income tax return information when completing
or updating my 2021-2022 FAFSA. (See “Income Verification” for Instructions).
My parent(s)’ SIGNED 2019 Federal IRS Tax Return Transcript or SIGNED and FILED 2019 income tax return is/are attached.
(See “Income Verification” for Instructions).
My parent(s) worked in 2019, but were not required to file a tax return. Their 2019 W-2s and IRS Verification of Nonfiling
Letter(s) are attached. (See “Income Verification” for Instructions).
Their earnings were: Parent 1: $ ____________________ Parent 2: $______________________
The Verification of Nonfiling Letter must be dated on or after October 1, 2020.
If your parent(s) were self-employed (including being paid “under the table”), please see “Income Verification”.
My parent(s) were not employed and had no income earned from work in 2019. My parent(s) were not required to file a tax return,
and have attached an IRS Verification of Nonfiling Letter (dated on or after October 1, 2020). (See “Income Verification”).
IRS Data Retrieval Tool (ONLY for 2019 Tax Filers who have an FSA ID):
The easiest way to verify income information for Single, Married Filing Jointly, and Head of Household tax filers is to use the IRS Data Retrieval Tool
(DRT) when completing the FAFSA on the Web. To use the DRT, the student must log-in to the FAFSA at StudentAid.gov with his/her FSA ID and select
“Make Corrections.” If the student was a 2019 tax filer and is attempting to use the DRT, the student will need to update the STUDENT 2019 tax return
status, type of return, and filing status. Follow-up questions will determine the student’s eligibility to use the DRT. If eligible to use the DRT, a button with
the title “Link to IRS” or a hyperlink titled “View options to link to IRS” will be available on the screen. On the IRS website, confirm that the student
information is correct, and type in the exact address used to file 2019 taxes. Click “Transfer Now.” If the transfer was successful, you will not be able
to see/review the data elements, but instead will see data elements labeled as “Transferred from IRS.” Please re-sign and re-submit the FAFSA.
If the parent(s) were 2019 tax filer(s) and are trying to use the DRT, a parent will need to update the parent 2019 tax return status, type of return, and filing
status. If the parent tax filer is eligible to use the DRT, the parent will need to enter their PARENT FSA ID (only one parent needs an FSA ID) before the
“Link to IRS” or “View option to link to IRS” option appears. The remainder of the process is THE SAME for the parent as the student.
2019 SIGNED Federal IRS Tax Return Transcript or SIGNED and FILED income tax return:
To request an IRS Tax Return Transcript, please visit www.irs.gov/individuals/get-transcript to download and print your 2019 transcript immediately, or
request the transcript be mailed to your address on record. Be sure to request a Tax Return Transcript, NOT an Account Transcript. The tax filer must sign
(handwritten signature only) and date the Tax Return Transcript before submitting the document to EWC. If you cannot get the transcript online, please
download
Form 4506-T by clicking on the “Transcript types” hyperlink on the IRS Get Transcript website. The tax filer will need to sign (handwritten
signature) and date the transcript before submitting the document to EWC. Transcripts can also be requested by calling the IRS Automated Telephone at
1-800-908-9946. If providing a tax return, you must include documentation indicating the return was filed, such as a preparer’s name and PTIN on the
return, or electronic confirmation of return submission. The return MUST be SIGNED before submitting to EWC. To request a copy of your income tax
return from the IRS (if unable to procure one from an accountant or tax filing software), you may complete
Form 4506. The tax filer will need to sign
(handwritten signature) and date the transcript before submitting the document to EWC.
2019 SIGNED Verification of Nonfiling Letter (ONLY for PARENTS who did not file taxes OR for those who were granted an Extension):
To request an IRS Verification of Nonfiling Letter, please visit www.irs.gov/individuals/get-transcript to download and print your 2019 Verification
of Nonfiling immediately, or request the letter be mailed to your address on record. The individual whose income is being verified will need to sign
(handwritten signature only) and date the Letter before submitting the document to EWC. If you cannot get the letter online, please download
Form 4506-T by clicking on “Transcript types” on the IRS Get Transcript website. The individual whose status needs confirmed will need to sign
(handwritten signature) and date the letter before submitting. You must check box 7 “Verification of Nonfiling” to request this document.
2019 W-2 Forms and Income Information (Non-Filers)
Please provide a copy of all 2019 W-2 forms from your employer(s). If you do not have or are unable to receive a copy from your employer(s), please
request an IRS Wage and Income Transcript at www.irs.gov/individuals/get-transcript. If you were self-employed and do not have W-2s, please submit a
statement confirming that you were self-employed; include your name(s), the type/name of your business, and your net income. The individual whose
income is being verified will need to sign (handwritten signature) and date the statement. PLEASE NOTE: you may be required to file a tax return even if
you had low net earnings. Please refer to the IRS Tax Guide (Page 6, Chapter 1) for self-employment filing criteria.
Fill in the information on the following pages as it applies to the student AND the student’s parent(s) whose information is on the
FAFSA. DO NOT LEAVE ANY ITEM BLANK. If any item does not apply, enter “N/A” for Not Applicable where a response is
requested, or enter $0 in an area where an amount is requested. ALL AMOUNTS ARE ANNUAL. To determine the correct annual
amount for each item: If you paid or received the same dollar amount every month in 2019, multiply that amount by the number of
months in 2019 you paid or received it. If you did not pay or receive the same amount each month in 2019, add together the amounts
you paid or received each month. If more space is needed for any item, attach a separate page with the student’s name, student ID #,
and appropriate information.
UNTAXED INCOME INFORMATION
INCOME VERIFICATION
A. Payments to tax-deferred pension and retirement savings
List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings plans, including, but not limited to, amounts
reported on W-2 forms (Boxes 12a through 12d with codes D, E, F, G, H, and S). Copies of all W-2 forms must be attached. See “Income
Verification” on the previous page for more information on requesting/providing W-2 forms and income information.
Name of person who made payment
Total amount paid in 2019
$
$
$
B. Child support received
List the amount of any child support RECEIVED in 2019 for any children listed on the first page of this worksheet as a household member.
Name of adult who received
the child support payment
Name of child for whom
child support was received
Age of
child
Total annual amount of child
support received in 2019
$
$
$
C. Housing, food, and other living allowances (these are often paid to members of the military, clergy, and others)
Total cash value that the student's parents received in 2019. If the student's parents received free room and board in 2019 for a job that was not
awarded to them as student financial aid, its value must be included in this figure.
DO NOT include rent subsidies for low-income housing, the
value of on-base military housing or the value of a basic military allowance for housing.
Name of recipient Type of benefit received
Total amount of benefit
received in 2019
$
$
D. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2019. Include Disability, Death Pension, Dependency and Indemnity
Compensation (DIC), and/or VA Educational Work-Study allowances. DO NOT include federal veterans educational benefits such as: Montgomery
GI Bill, Dependents Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill.
Name of recipient
Type of Veterans
non-education benefit received
Total amount of benefit
received in 2019
$
$
E. Other untaxed income
List the amount of other untaxed income not reported and not included elsewhere on this form. Include items such as workers’ compensation,
disability benefits, untaxed portions of health savings accounts from IRS Form 1040 Schedule 1—line 12, Railroad Retirement Benefits, etc.
DO NOT include student aid, Earned Income Credit, Additional Child Tax Credit, welfare benefits, untaxed Social Security benefits, Supplemental
Security Income (SSI), Workforce Innovation and Opportunity Act educational benefits, on-base housing or military housing allowance, combat pay,
benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.
Name of recipient
Type of other
untaxed income received
Total amount of other untaxed
income received in 2019
$
$
$
F. Money received or paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g., payment of a bill) not reported elsewhere on this form. Include support from a parent
whose information was NOT on the student’s FAFSA, but DO NOT include information from a parent whose information IS included on the FAFSA.
Amounts paid on the student’s behalf also include any distributions to the student from a 529 plan owned by someone other than the student or
student’s parents, such as a grandparent, aunt, and/or uncle of the student.
Purpose (e.g., cash, rent, books,
cell phone bill, car insurance, etc.)
Source of payment (parent NOT
on FAFSA, grandparent, etc.)
Total amount
received in 2019
$
$
HIGH SCHOOL COMPLETION STATUS
CERTIFICATIONS AND SIGNATURES
G. Additional information
So that we may fully understand the student’s family’s financial situation, please provide the below information about any other resources, benefits,
and other amounts received by the student and any members of the student’s household. This may include items that were not required to be reported
on the FAFSA or other forms submitted to the financial aid office, and include such things as federal veterans education benefits, military housing,
low-income housing, SNAP, Medicaid, TANF, WIC, Supplemental Security Income, etc.
Name of recipient
Type of Benefit (e.g., veterans, military,
low-income, Medicaid, WIC, SSI, etc.)
Total amount
received in 2019 (if known)
$
$
$
Please explain IN DETAIL how your family supported itself in 2019. Please include whether or not you lived with someone else who
helped support you/your family, or received assistance not otherwise listed on this form. Because FAFSA information requires 2019
income information which may not reflect your current situation, please also explain IN DETAIL how your family is supporting itself
now, including any changes in employment, benefits, or other income since 2019. You may attach a separate sheet if needed.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
Please provide ONE of the following documents that indicates what your high school completion status will be when you will begin
college in 2021-2022. Submit it with this form and any other documentation requested.
A copy of your high school diploma.
Your final official high school transcript that shows the date when the diploma was awarded.
Your official General Educational Development (GED)* certificate or transcript.
Documentation of the HiSET/TASC or other high school equivalency exam is also acceptable.
An official academic transcript that indicates you successfully completed at least a two-year program that is acceptable for full
credit toward a bachelor’s degree.
Please note: Credits transferred in from previous institutions attended may affect your maximum time frame calculation as defined
in EWC’s Satisfactory Academic Progress Policy.
If you were home schooled in Wyoming, a copy of your transcript or the equivalent, signed by a parent or guardian, along with
EWC’s Completion of Secondary Education Form for Home Schooled Students.
If you were home schooled in another state and your state requires home schooled students to obtain a secondary school
completion credential for home school (other than a high school diploma or its recognized equivalent), a copy of that credential.
If you are unable to obtain any of the forms of documentation listed above, please contact the Financial Aid Office.
By signing this worksheet, we certify that all of the information reported is complete and correct. We also acknowledge that we have read
and agree to comply with all verification policies as stated by EWC in the College Catalog and on the EWC website. Failure to submit
information in a timely fashion may result in the application being filed as inactive with no further consideration and no federal aid
for the academic year. Student and parent must sign:
____________________________________________________ ___________________________________________________
Student’s signature Date Parent’s signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.
STATEMENT OF SUPPORT
MUST COMPLETE ATTACHED FORM—READ DIRECTIONS CAREFULLY
2021-2022 IDENTITY AND STATEMENT OF EDUCATIONAL PURPOSE
The student must apply in person at Eastern Wyoming 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 official at the institution authorized to collect the student’s ID.
In addition, the student MUST sign, in the presence of an institutional official, the Statement of Educational Purpose provided
below. If the student is unable to appear in person at EWC to verify his or her identity, the student must provide to the institution:
(a) 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
(b) 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.
DO NOT COMPLETE THIS FORM IN ADVANCE.
Statement of Educational Purpose
I certify that I __________________________________________________ am the individual signing this
(print student’s name)
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 Eastern Wyoming College for 2021-2022.
Student signature:
Date: Student ID #:
Declaración de Propósito Educativo
Certifico que yo, __________________________________________________ soy el individuo que firma esta
(imprimir Nombre del estudiante)
Declaración de de Propósito Educativo, y que la ayuda financiera federal estudiantil que yo pueda recibir, sólo
será utilizada para fines educativos y para pagar el costo de asistir a Eastern Wyoming College para 2021-2022.
Firma del estudiante:
Fecha: __________________________ Número de identificaciôn del estudiante:___________________
IF SUBMITTING IN PERSON
Present this form with original valid government-issued photo ID, such
as, but not limited to, a driver’s license, other state issued ID, or passport.
IF SUBMITTING BY MAIL
Submit this original notarized form with photocopy of valid
government-issued photo ID to EWC.
To be completed by EWC Financial Aid Administrator
or EWC Outreach Coordinator (FAA/OC):
To be completed by Notary Public:
ID Type:
State of: City/County of:
ID Number:
Exp:
On (date):
Before me:
(notary’s name)
FAA/OC Name:
Personally appeared (printed name of signer):
FAA/OC Title/location:
On basis of satisfactory evidence of identification:
(Type of government-issued photo ID provided)
FAA/OC Signature:
Date:
To be the above-named person who signed the
foregoing instrument.
Notary signature:
WITNESS my hand and official seal:
My commission expires on: ________________________
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2021-2022 Dependent V5 Worksheet (Eastern Wyoming College)

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Completed 4 February 2021

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