*DECSP*
115 South Street Middletown, NY 10940 (845)341-4190 fax (845)341-4194
1 Washington Center Newburgh, NY 12550 (845) 562-245 fax (845)220-4062
www.sunyorange.edu
1516 DEPENDENT CHILD SUPPORT PAID VERIFICATION FORM (V3)
Your 2015 -2016 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called
Verification. The law says before awarding Federal Student Aid, we may ask you to confirm the information you reported on
your FAFSA. To verify that you provided correct information the financial aid administrator at your school will compare your
FAFSA with the information on this worksheet and with any other required documents. If there are differences, your FAFSA
information may need to be corrected. You must complete and sign this worksheet, attach any required documents, and
submit the form and other required documents to the financial aid administrator at your school. Your school may ask for
additional information. If you have questions about verification, contact your financial aid administrator as soon as possible
so your financial aid will not be delayed.
A. STUDENT INFORMATION
Student ID #__________________________
First Name:__________________________________MI_____Last Name:____________________________________
Date of Birth: ___/ ___/ ______ Phone:(______)______ - _________ _E-mail___________________ @__
B. DEPENDENT STUDENT'S HOUSEHOLD CHILD SUPPORT PAID INFORMATION TO BE VERIFIED
Did someone in the student's household pay child support in 2014?
(check ONLY one)
No
Yes, I will provide documentation from the issuing agency (copy of benefit card is not acceptable)
If yes, I have listed below the names of the persons to whom the child support was paid, the names of the children for whom the child
support was paid and the total amount of child support paid in 2014 for each child. I also attest that I have not included these children as
members of my household size. (Parents can either include these children as members of the household *or* include the amount of child
support paid but may not include these children as members of the household and also list child support paid.
Name who paid the child support
Name who received the support
Electronic Certification Agreement. By providing your “electronic” student signature, student ID # and by selecting the
“Accept" button, you consent that all of the information reported is complete and correct.
Student: Accept
Student Signature:______________________________________Date:___/ ___/ _____
Parent: Accept
Parent Signature:_______________________________________Date: ___/ ___/ _____
WARNING: If you purposely give false or misleading information on the worksheet, you may be fined, be
sentenced to jail, or both.
PLEASE NOTE: A DEPENDENT VERIFICATION WORKSHEET AFFIDAVIT (DAVD)
MUST ALSO BE COMPLETED AND SUBMITTED TO THE FINANCIAL AID OFFICE.
