Instructions: fill out form, choose ‘print’ icon then ‘save as pdf’ and email form from your device to financialaid@rpcc.edu
2021-2022 INDEPENDENT HOUSEHOLD WORKSHEET (V1)
Student’s Name: _________________________________________ Student ID #: _____________________________________
Mailing Address: _____________________________________________ Phone Number: _________________________________
Email Address: ______________________________________________________________________________________________
SECTION 1: HOUSEHOLD MEMBERS
List below the people considered in the student’s household for FAFSA purposes, including:
The student.
The student’s spouse, if the student is married.
Any children that the student and/or spouse will provide more than half of the support for, from July 1, 2021 through June
30, 2022.
Other people if they now live with the student and the student or spouse provides more than half of the other person’s
support, and will continue to provide more than half of that person’s support through June 30, 2022.
Include the name of the college for any household member who will be enrolled at least half-time in a degree, diploma, or
certificate program at a postsecondary educational institution any time between July 1, 2021, and June 30, 2022.
Include all household members, even those who are not in college but meet the criteria listed above.
If more space is needed, provide a separate page with the student’s name at the top.
Full Name Age
Relationship to
Student
If enrolled in College, list full
Name of College
Enrolled in College
at Least Half Time?
self
[ ] yes [ ] no
[ ] yes [ ] no
[ ] yes [ ] no
[ ] yes [ ] no
[ ] yes [ ] no
[ ] yes [ ] no
Note: We may require additional documentation if we have reason to believe that the information regarding the household members
enrolled in eligible postsecondary educational institutions is inaccurate.
Office of Financial Aid & Scholarships
Gonzales-Westside-Reserve-St. Charles Campuses
Financialaid@rpcc.edu
SECTION 2: STUDENT (AND SPOUSE, IF APPLICABLE) TAX FILING STATUS
Check the box that applies (Only check one (1) box):
The student (and spouse if applicable) has used the IRS DRT in FAFSA on the Web to transfer 2019 IRS income tax return information
into the student’s FAFSA.
The student (and spouse if applicable) has not yet used the IRS DRT in FAFSA on the Web, but will use the tool to transfer 2019 IRS
income tax return information into the student’s FAFSA.
The student (and spouse if applicable) is unable or chooses not to use the IRS DRT in FAFSA on the Web, and instead will provide the
school with a 2019 IRS Tax Return Transcript(s).*
The student (and spouse if applicable) did work in 2019, but did not file and was not required to file a 2019 income tax return with the
IRS. Please complete the chart below and attach copies of all W-2’s or 2018 IRS Wage Statement.
List every employer even if the employer did not issue an IRS W-2 form. If more space is needed, attach a separate page
with your name and SSN at the top.
Employer’s Name
2018 Amount Earned
2019 IRS Tax Return Transcript may be obtained through:
Get Transcript by MAIL Go to www.irs.gov, under the Tools heading, click "Get a tax transcript.” Click “Get Transcript by MAIL.” Make sure to request the “IRS Tax
Return Transcript” and NOT the “IRS Tax Account Transcript.” The transcript is generally received within 10 business days from the IRS’s receipt of the online request.
Get Transcript ONLINEGo to
www.irs.gov, under the Tools heading, click "Get a tax transcript." Click “Get Transcript ONLINE.” Make sure to request the “IRS Tax
Return Transcript” and NOT the “IRS Tax Account Transcript.” To use the Get Transcript Online tool, the user must have (1) access to a valid email address, (2) a text-
enabled mobile phone (pay-as-you-go plans cannot be used) in the user’s name, and (3) specific financial account numbers (such as a credit card number or an
account number for a home mortgage or auto loan). The transcript displays online upon successful completion of the IRS’s two-step authentication.
Automated Telephone Request – 1-800-908-9946. Transcript is generally received within 10 business days from the IRS’s receipt of the telephone request.
Paper Request FormIRS Form 4506T-EZ or IRS Form 4506-T. The transcript is generally received within 10 business days from the IRS’s receipt of the paper request
SECTION 3: CERTIFICATION AND SIGNATURES
Each person signing this worksheet certifies that all of the information reported on it and on accompanying documents are complete and correct.
If you purposely provide false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
The student (and spouse) must sign and date:
_______________________________________________ _________________________________
Student’s Signature Date
_______________________________________________ __________________________________
Spouse’s Signature (if applicable) Date