*DEVER4*
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 OTHER VERIFICATION FORM (V4)
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 OTHER INFORMATION TO BE VERIFIED
Did someone in the student's household receive benefits from the Supplemental Nutrition Assistance Program/SNAP (formerly
known as food stamps) any time during the 2013 or 2014 calendar years?
No
Yes, I will provide documentation from the issuing agency (copy of benefit card is not acceptable).
Did someone in the student's household, pay child support in 2014?
No
Yes
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.
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.
Name who paid the child support
Name who received the support
