_______________________________________________________ _______________________________ ______
Dependent Verification Worksheet
2017
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2018
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 your California Dre am Act Application (AB540 or AB2000) with a n IRS 2015 Federal Tax Return
Transcript, information from thi s form, and other documents provided by you and your parents. Und e r the l aw, 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 at least half‐time between July 1
st
2017 and June 30th, 2018.
First and Last Name of Family Member
College Attending 17
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18
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
Federal IRS Tax Return T
ranscript OR a Non-Tax Filers Statement
call the IRS at
1‐800‐908‐9946 or go to http://www.irs.gov/Individuals/Order‐a‐Transcript .
Student
Parent
__
_
I filed a 2015 1040 tax return and used the IRS Data Retrieval Tool
I filed a 2015 1040 tax return and have attached my IRS Tax Transcript
I was employed in 2015 but am not required to file a 1040
Submit with W- 2 forms
I was not employed and had zero income from work in 2015
I/we filed a 2015 1040 tax return and used the IRS Data Retrieval
Tool
I/we filed 2015 1040 tax return and have attached my IRS Tax
Transcript
I/we was employed in 2015 but am not required to file a 1040
Submit W-2 forms
I/we was not employed and had zero income from work 2015
C. Untaxed Income and Benefits
Indicate the untaxed income received in 2015 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's Signature Date
Parent's Signature Date
1570 East Colorado Blvd., Pasadena, California 91106
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2003
18DV1
