*INVER4*
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 INDEPENDENT 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. INDEPENDENT STUDENT'S 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?
(check ONLY one)
No
Yes, I will provide documentation from the issuing agency (copy of benefit card is not acceptable).
Did you or your spouse, if married, pay child support in 2014?
(check ONLY one)
No
Yes, 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
D. CERTIFICATIONS AND SIGNATURES
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:___/ :__/ :_____
Spouse: Accept ___
Spouse Signature:______________________________________Date:___/ :__/ :_____
(if required)
WARNING: If you purposely give false or misleading information on the worksheet, you may be fined, be
sentenced to jail, or both.
