Fillable Dependent V5 Rev (California State University Channel Islands)

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Dependent V5 Rev (California State University Channel Islands)

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FA-25 / 18-19 REV Page 1 of 5
2018-2019 Verification Worksheet
Dependent - Aggregate Verification Group (V5)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
Student Last Name
Student First Name
CSUCI ID Number
Student Phone Number
DO NOT SUBMIT THIS FORM UNLESS IT WAS REQUESTED BY OUR OFFICE
Purpose
Your 2018-2019 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. You and at least one
parent must complete and sign this worksheet, attach any required documents, and submit the form and other required documents to the Financial
Aid & Scholarships office. We may also ask for additional information upon further review. If you have special circumstances or require further
instructions, please contact our office at financial.aid@csuci.edu or (805) 437-8530.
A. Household Information
1. Complete the following information about yourself:
First and Last Name
Age
Relationship to Student
Name of College student will attend in 2018-2019*
Self
CSU Channel Islands
2. Fill out the name and age of any parent (including a step-parent) who you listed on your FAFSA.
Do not include a parent who is not living in the household due to separation, divorce, or death.
First and Last Name
Age
Relationship to Student
Parent
Parent
3. Do you have any siblings who either:
a) your parents will provide more than half of their support from July 1, 2018 through June 30, 2019 OR
b) have completed a 2018-2019 FAFSA and included your parents information?
Yes (complete the chart below)
No (skip to next question)
First and Last Name
Age
Relationship to Student
Name of College relative will attend in 2018-2019*
Sibling
Sibling
Sibling
Sibling
4. Are there any other people who live with your parents and your parents will provide more than half of their support from July 1, 2018 through
June 30, 2019? (For example: your children, your unborn child and/or your parent's unborn child, if that child will be born before June 30, 2019)
Yes (complete the chart below)
No (skip to next section)
First and Last Name
Age
Relationship to Student
Name of College relative will attend in 2018-2019*
* 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, 2018 and June 30, 2019. If more space is needed, attach a separate page with student's name and CI ID# at the top.
FA-25 / 18-19 REV Page 2 of 5
2018-2019 Verification Worksheet
Dependent - Aggregate Verification Group (V5)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
Acceptable Documentation for Taxable Income
The best way to verify taxable income is by utilizing the IRS Data Retrieval Tool (IRS DRT) that is part of the FAFSA on the Web at fafsa.gov. If you
are unable or choose not to use the IRS DRT, and you filed taxes in 2016, then you are required to submit your 2016 IRS Tax Return Transcript to
the Financial Aid & Scholarships office.
Do NOT email any IRS Tax Return Transcripts or other IRS documents (i.e. Form W-2, Form 4868, Verification of Non-filing Status, etc.) to our
office unless you securely encrypt the email attachments. For more information on encryption and data security, visit our website at
www.csuci.edu/financialaid/data-security
B. Student's Income Information
Did, or will, you, the student, file a 2016 income tax return with the IRS?
Yes (select one option from column below)
No (select one option from column below)
Student Tax Filers
Student Nontax Filers
I have used the IRS Data Retrieval Tool (IRS DRT)
I was not employed and had no income earned from work in
2016
I am unable or choose not to use the IRS DRT
Submit a signed copy of your 2016 1040 Tax Return or a
copy of your 2016 IRS Tax Return Transcript*
I was employed in 2016
Submit a copy of all your 2016 Form W-2(s) from your
employers or your 2016 IRS Wage and Income Transcript*
List the names of all your employer(s) and the amount
earned from each employer in 2016
I will file, but have not yet completed my return because I have
been approved for an extension beyond the October 2017
deadline
Submit Verification of Non-filing for 2016*
Submit a copy of your 2016 IRS Form 4868
Submit a copy of a letter from the IRS confirming you were
approved for an extension beyond six months
Submit a copy of all your 2016 Form W-2(s) from your
employers or a 2016 IRS Wage and Income Transcript*
If you were self-employed, submit a typed and signed
statement (use the "Financial Aid Statement Form") with the
amount of your 2016 Adjusted Gross Income (AGI) and
estimated U.S. income taxes paid
Employer's Name
2016 Amount
Earned
Example:
Suzy’s Auto Body Shop
Example:
$2,000.00
If you are unable to provide the documents please contact our
office for further instruction.
* For further instruction, refer to the IRS Tax Transcript Information sheet found on our website at www.csuci.edu/financialaid/financial-aid-forms
Parent Marital and Tax Filing Status
If two parents were reported in Section A of this worksheet, the instructions and certifications below refer to and apply to both parents.
Check the appropriate box for your parents: (for informational purposes only)
FAFSA marital status is “Married or remarried” and my parents' tax filing status for 2016 was “Married Filing Jointly”
You must use the IRS DRT available on the FAFSA OR you must attach a copy of your parents' 2016 IRS Tax Return Transcript
FAFSA marital status is “Married or remarried” and my parents' tax filing status for 2016 was “Married Filing Separately”
You must attach a copy of BOTH your parents' 2016 IRS Tax Return Transcript
FAFSA marital status is “Divorced or separated” or “Widowed” and my parents’ tax filing status for 2016 was “Married Filing Jointly”
You must attach a copy of your parents' 2016 IRS Tax Return Transcript AND copies of all their 2016 Form W-2(s)
FAFSA marital status is “Unmarried, both legal parents living together”
You must attach a copy of BOTH parents' 2016 IRS Tax Return Transcripts
None of these options apply
FA-25 / 18-19 REV Page 3 of 5
2018-2019 Verification Worksheet
Dependent - Aggregate Verification Group (V5)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
C. Parent's Income Information
Did, or will, your parent(s), file a 2016 income tax return with the IRS?
Yes (select one option from column below)
No (select one option from column below)
Parent Tax Filers
Parent Nontax Filers
My parents have used the IRS Data Retrieval Tool (IRS DRT)
Neither parent was employed, and neither had income earned
from work in 2016
Submit Verification of Non-filing for 2016* for each parent
My parents are unable and choose not to use the IRS DRT
Submit a signed copy of your parent(s) 2016 1040 Tax
Return or a copy of their 2016 IRS Tax Return Transcript*
One or both parents were employed in 2016
Submit Verification of Non-filing for 2016* for each parent
Submit a copy of all your parent(s) 2016 Form W-2(s) from
their employers or your parent(s) 2016 IRS Wage and
Income Transcripts*
List the names of all parents’ employer(s) and the amount
earned from each employer in 2016
My parents will file, but they have not yet completed their
return because they have been approved for an extension
beyond the October 2017 deadline
Submit Verification of Non-filing for 2016* for each parent
Submit a copy of your parent(s) 2016 IRS Form 4868
Submit a copy of a letter from the IRS confirming your
parent(s) were approved for an extension beyond six
months
Submit a copy of all your parent(s) 2016 Form W-2(s) from
their employers or your parent(s) 2016 IRS Wage and
Income Transcripts*
If your parent(s) were self-employed, submit a typed and
signed statement (use the "Financial Aid Statement Form")
with the amount of their 2016 Adjusted Gross Income
(AGI) and estimated U.S. income taxes paid
Employer's Name
2016 Amount
Earned
Example:
Alfred’s Auto Body Shop
Example:
$2,000.00
If you are unable to provide the documents please contact our
office for further instruction.
* For further instruction, refer to the IRS Tax Transcript Information sheet found on our website at www.csuci.edu/financialaid/financial-aid-forms
D. Untaxed Income Information
1. In 2016, did you or your parent(s) have any untaxed portions of an
IRA Distribution(s) that was a rollover?
2. In 2016, did you or your parent(s) have any untaxed portions of a
Pension(s) Distribution(s) that was a rollover?
Yes… Total rollover amount for 2016: $
Yes … Total rollover amount for 2016: $
No
No
E. High School Completion Status
Please check the box (ONLY ONE) that indicates the student’s high school completion status:
High School Diploma
Please submit:
A copy of the student's high school diploma; or
A copy of the student's final high school transcript that shows the date when the diploma was awarded
State Certificate (includes GED)
Please submit:
A copy of the certificate/transcript the student received after passing a state-authorized examination, which the state recognizes as the
equivalent of a high school diploma (GED test, HiSET, TASC, or other State-authorized examination)
FA-25 / 18-19 REV Page 4 of 5
2018-2019 Verification Worksheet
Dependent - Aggregate Verification Group (V5)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
Two-Year Program Completion
Please submit:
A copy of the student's academic transcript that indicates the student has completed at least a two-year program that is acceptable for
full credit toward a bachelor's degree
Foreign Country Secondary School Leaving Certificate
Please submit:
A copy of the student’s “secondary school leaving certificate” or other similar document
Home Schooled Student
Please submit:
When State law requires the student to obtain a secondary school completion credential for homeschooling:
A copy of that credential
When State law does not require the student to obtain a secondary school completion credential for homeschooling:
A transcript or the equivalent, signed by the student's parent or guardian, that lists the secondary school courses the student has
completed and documentation that the student has successfully completed secondary school education in a homeschool setting
NOTE: If the student is unable to obtain the documentation requested to support their high school completion status, or, the student has
provided this information in a prior year, the student must contact the Financial Aid & Scholarships office.
F. Certification and Signature
The student and one parent must sign and date below. Each person signing this worksheet certifies that all of the information reported on this form is
true and accurate to the best of their knowledge.
WARNING:
If you purposely give false or
misleading information on this
form, you may be fined, sentenced
to jail, or both.
Student Signature (electronic signatures not accepted)
Date
Parent Signature (electronic signatures not accepted)
Date
FA-25 / 18-19 REV Page 5 of 5
2018-2019 Verification Worksheet
Dependent - Aggregate Verification Group (V5)
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
G. Identity and Statement of Educational Purpose
Identity and Statement of Educational Purpose (To Be Signed at the Institution)
The student must appear in person at California State University Channel Islands (CSUCI) 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 receive and review the student’s ID.
In addition, the student must sign, in the presence of the institutional official, the Statement of Educational Purpose provided below.
I certify that I,
, am the individual signing this Statement of Educational Purpose and that the Federal student
(Print Student's Name)
financial assistance I may receive will only be used for educational purposes and to pay the cost of attending California State University Channel Islands
(CSUCI) for 2018-2019.
Student Signature
Date
Student’s ID Number
Financial Aid Administrator Signature
Date
Identity and Statement of Educational Purpose (To Be Signed in the Presence of a Notary)
If the student is unable to appear in person at California State University Channel Islands (CSUCI) 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.
I certify that I,
, am the individual signing this Statement of Educational Purpose and that the Federal student
(Print Student's Name)
financial assistance I may receive will only be used for educational purposes and to pay the cost of attending California State University Channel Islands
(CSUCI) for 2018-2019.
Student Signature
Date
Student’s ID Number
Notary’s Certificate of Acknowledgement
State of
City/County of
on
before me
personally appeared
and proved to me on the basis of satisfactory
(Notary’s Name)
(Printed name of signer)
evidence of identification,
, to be the above-named person who signed the foregoing instrument.
(Type of government-issued photo ID provided)
WITNESS my hand and official seal
(seal)
(Notary Signature)
(Date commission expires)
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Dependent V5 Rev (California State University Channel Islands)

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Completed 24 July 2020

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