Financial Aid Office
3200 West C Street
Torrington, WY 82240
p: 307.532.8224
f: 307.532.8222
financialaid@ewc.wy.edu
2017-2018
Dependent Institutional Verification
Worksheet (V6)
Students selected for institutional verification must also complete the Standard Verification (V1) Worksheet and MUST provide
copies of all 2015 W-2 forms for the student and parent(s) in order for the verification process to be complete.
If you or your parent(s) were self-employed and do not have W-2s available, you will need to submit a statement that includes your
name(s), the type/name of your business, your gross income, and why you were unable to provide W-2s (e.g., self-employment). The
individual whose income is being verified will need to sign (handwritten signature) and date the statement before submitting to EWC.
______________________________________________________________ ________________________________________
Last Name First Name M.I. EWC Student ID Number
Fill in the information below 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 2015, multiply that amount by the number of months in 2015 you paid or
received it. If you did not pay or receive the same amount each month in 2015, 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.
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.
Name of person who made payment
Total amount paid in 2015
$
$
B. Child support received
List the amount of any child support RECEIVED in 2015 for any children listed on the Standard Verification (V1) 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 2015
$
$
$
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 2015. If the student's parents received free room and board in 2015 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
D. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2015. 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
STUDENT INFORMATION
UNTAXED INCOME INFORMATION
11/2016
E. Other untaxed income
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include items such as disability, workers’
compensation, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25, Railroad Retirement Benefits, etc.
DO NOT include student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social
Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, 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
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 grandparent, aunts and uncles 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 2015
$
$
G. Additional information
So that we may fully understand the student’s family’s financial situation, please provide 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 2015
$
$
Please explain IN DETAIL how your family supported itself in 2015. Because FAFSA information requires 2015 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 from 2015. You may attach a separate sheet if needed.
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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.
CERTIFICATIONS AND SIGNATURES
STATEMENT OF SUPPORT