______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Dependent
2019-2020 Verification Worksheet
OFFICE OF FINANCIAL AID
Your Free Application for Federal Student Aid (FAFSA) was selected
for a “Verification” process which compares information from your
FAFSA with your and your parent(s) 2017 Federal income tax
information and/or other financial documents. Based on this
review, Purdue University Northwest may need to make electronic
corrections to your FAFSA information. Verification must be
completed by Sept. 30, 2020 or 120 days after your last day of
enrollment for 2019-2020, whichever is earlier. Verification
includes receipt of a valid and correct Institutional Student
Information Record (ISIR) with an official Expected Family
Contribution (EFC). Financial aid will not be disbursed until the
verification process is complete.
Federal Law requires Purdue University Northwest review the requested
information under the financial program rule 34CFR, Part 668.
What you should do
1. Complete, sign and submit this Verification Worksheet. You
and at least one parent must sign.
2. Submit your and your parent(s) 2017 IRS Tax Return
Transcript(s), if required, and any other requested
documents to the Office of Financial Aid. IRS Tax
Return Transcripts may be requested from the IRS on-
line at www.irs.gov or by calling 1-800-
908-9946.
3. If the student and/or parent, filed or will file, an
Amended 2017 IRS Tax Return, contact the Office of
Financial Aid at Purdue University Northwest.
Note: Deadline for submitting verification information is September 1,
2019. Eligibility for financial aid will not be determined until
verification is complete.
SECTION 1: To be completed by all students.
A. Student Information
Last Name First MI PUID
Address (include apt. no.) Date of Birth (month/day/year)
City State ZIP code Home Phone Number (include area code)
E-Mail Address Cell Phone Number (include area code)
B. Family Information
List the people
in your parent(s) household, include:
Yourself and your parent(s) (including stepparent) even if you don’t live with your parent(s).
Your parents’ other children, even if they don’t live with your parent(s), if (a) your parent(s) will provide more than half
of their support from July 1, 2019 through June 30, 2020 or (b) the children would be required to provide parental
information when applying for Federal Student Aid.
Other people if they now live with your parent(s), and your parent(s) provide more than half of their support and will
continue to provide more than half of their support from July 1, 2019 through June 30, 2020.
Write the names of all household members in the space(s) below. Also write in the name of the college for any household
member, excluding your parent(s), who will be attending college at least half-time between July 1, 2019 and June 30,
2020 and will be enrolled in a degree, diploma, or certificate program. If you require additional space, please attach a
separate page.
Full Name Age Relationship College
Self
Purdue University Northwest
(Over)
Hammond Campus
2200 169th Street * Hammond, IN 46323
(219) 989-2301 * FAX: (219) 989-2141
Westville Campus
1401 S. U.S. Hwy. 421 * Westville, IN 46391
(219) 785-5460 * FAX: (219) 785-5653
Toll-Free: 1-855-608-4600
website: pnw.edu
Dependent
SECTION 2: C
omplete this section ONLY IF you did NOT transfer your 2017 tax information directly from the IRS to your
FAFSA wh
en completing your FAFSA online OR you made changes to the information transferred from the IRS.
______________________________________________ _______________________________
______________________________________________
_______________________________
Student’s Tax Information: (Check only one box below)
Check here and attach your 2017 IRS Tax Return Transcript. A Tax Return Transcript may be requested from the
Internal Revenue Service online at www.irs.gov or by calling 1-800-908-9946. And, if you filed an Amended
Income Tax Return, you must also attach a signed copy of your 2017 IRS Form 1040X that was filed with the IRS.
Check here if you will not file and are not required to file a 2017 Federal tax return.
(Note: If you did not file and are not required to file a 2017 Federal tax return, list your employer(s) and any
income you received in 2017 Attach copies of all 2017 W-2 forms and other earnings statements for
each source of income received in 2017.)
Sources of Income and / or Child Support Received
2017 Amount
$
$
SECTION 3: Complete this section ONLY IF your parent(s) did NOT transfer their 2017 tax information
directly from the IRS to your FAFSA when completing your FAFSA online OR they made changes to the information
transferred from the IRS.
Parent’s Tax Information: (Check only one box below)
Check here and attach your parent(s) 2017 IRS Tax Return Transcript. A Tax Return Transcript may be
requested from the Internal Revenue Service on-line at www.irs.gov or by calling 1-800-908-9946. And, if your
parent(s) filed an Amended Income Tax Return, you must also attach a signed copy of your parent(s) 2017 IRS
Form 1040X that was filed with the IRS.
Check here if your parent(s) will not file and are not required to file a 2017 Federal tax return. Parent(s) must
attempt to retrieve their IRS Tax Return Transcript and provide the document with the resulting
message from the IRS that states they did not file a return for 2017.
(Note: If your parent(s) did not file and are not required to file a 2017 Federal income tax return, list your
parent(s) employer(s) and any income they received in 2017. Attach copies of all 2017 W-2 forms and
other earnings statements for each source of income received in 2017.)
Sources of Income and / or Child Support Received
2017 Amount
$
$
SECTION 4: Sign this Verification Worksheet.
By signing this Verification worksheet we certify that all
information reported on it is complete and correct.
At least one Parent must sign.
WARNING: If you purposely give false or misleading
information on this Verification Worksheet you may be
fined, be sentenced to jail, or both.
Student’s Signature Date
Parent’s Signature
Date
Do not mail this worksheet to the U. S. Department of Education. Submit this worksheet, along with all IRS Tax Return Transcript(s),
if required, and any other requested documents to the Office of Financial Aid at Purdue University Northwest.
Office Use Only - RRAAREQ: _____DVER20 (R) _____STRN20 (C/R) ____PTRN20 (C/R) _____SW2-20(R) _____PW2-20(R) _____STRX20 (R) _____PTRX20 (R)
$
$
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome