_______________________________________________________ _______________________________ ______
Dependent Verification Worksheet
2018
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2019
Student ID
Last Name
First Name
M.I.
Your application was selected by the US Department of Education for a process called "Verification". In this process, Pasadena City College's (PCC) Office of
Financial Aid will compare information on your FAFSA or California Dream Act Application (AB540 or AB2000) with an IRS 2016 Federal Tax Return
Transcript, information from this form, and other documents provided by you and your parents. Under the law, the college has the right to ask you for this
information before awarding federal and state aid.
A. Family Information
List yourself, your parent(s), and anyone else your parent(s)/step‐parent provides more than 50% support for (excluding foster children). Write in the name of
the college for any household member (excluding parents) who will be attending College at least half‐time between July 1
st
2018 and June 30th, 2019.
First and Last Name of Family Member
College Attending 18
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19
B. Student and Parent Tax
Form
To use the FAFSA
IRS Data Retrieval
Tool
, go to
http://www.FAFSA.gov .
To request a copy of your 2016
Federal IRS Tax Return T
ranscript OR a IRS Verification ofNon-Tax Filers Letter
call the IRS at
1-800-908-9946 or go to http://www.irs.gov/Individuals/Order‐a‐Transcript .
Student
Parent
__
_
I filed a 2016 1040 tax return and used the IRS Data Retrieval Tool
I filed a 2016 1040 tax return and have attached my IRS Tax Transcript
I was employed in 2016 but am not required to file a 1040
Attach 2016 W-2 Forms
I was not employed and had zero income from work in
201 6
I/we filed a 2016 1040 tax return and used the IRS Data
Retrieval Tool
I/we filed 2016 1040 tax return and have attached my IRS Tax
Transcript
I/we was employed in 2016 but am not required to file a 1040
An IRS Verification of Non-Tax Filers is required along with W-2 forms
I/we was not employed and had zero income from work 2016
An IRS Verification of Non-Tax Filers Letter is required
C. Untaxed Income and Benefits
Indicate the untaxed income received in 2016 and the amount. This can include money you or your parent’s received from sources in the US or another country. Include all
sources of income used to pay for living expenses including cash support, Veteran’s non
‐‐‐
education benefits, and/or general relief.
Student Parent
Income from Work (not reported on your 1040) $_________ Income from Work (not reported on your 1040) $_________
Employer_____________________________________ Employer________________________________
Money from Foreign Income $_________ Money from Foreign Income $_________
Money Received on your behalf, other Untaxed Income $_________ Money Received on your behalf, Untaxed Income $_________
Certification:
I hereby certify that all information reported on this form and any attachments are true, complete, and accurate. Further, I understand that false statements
and/or misrepresentations will result in denial or reduction, withdrawal, and/or repayment of aid disbursed and student disciplinary action may be taken.
Student Signature
Parent Signature
Date
Date
1570 East Colorado Blvd., Pasadena, California 91106
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2003
19DEPV
