Fillable FA103 DVWS20 (Coconino Community College)

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FA103 DVWS20 (Coconino Community College)

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DVWS20
DEPENDENT VERIFICATION WORKSHEET
(2019-2020 Academic Year – V1, V5)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-104 DVWS20 20190312
Your financial aid file was selected for a process called verification. Department of Education Regulation 34 CFR, Part
668 requires colleges to compare your household’s 2017 financial documentation with the information provided on your
Free Application for Federal Student Aid (FAFSA). This process must be completed before CCC can award you financial
aid. If there are differences between your FAFSA and your financial documents, CCC will correct your FAFSA. We may
require additional documentation if we have reason to believe the information on this form is inaccurate or incomplete.
Instructions for Section A:
Dependent Students (If you were required to report your parent’s information on the FAFSA)
1. List yourself and your parent(s), including legal stepparent, even if you do not live with your
parent(s).
2. List your parent(s) other children, even if they do not live with your parent(s) if your parent(s) will
provide more than half of their support from July 1, 2019 through June 30, 2020.
3. List other people currently living with your parent(s) for whom they will provide more than half of
their support from July 1, 2019 through June 30, 2020.
4. If you are unsure of who to list, please call us at 928-226-4219 so we can assist.
SECTION A. Complete this chart about the people in your household. Follow the above instructions carefully.
Household Member’s
First Name and Last Name
Age
Relationship
(to the
student)
College Attending in 2019-20
(if applicable)
Will this person be
enrolled at least
half time in a
degree, diploma or
certificate
program?
Y/N
Self
Coconino Community College
CCC ID# Last Name First Name MI
Mailing Address City State Zip Code
Telephone No. (include area code) Email Address
DVWS20
DEPENDENT VERIFICATION WORKSHEET
(2019-2020 Academic Year – V1, V5)
2800 S Lone Tree Rd Flagstaff, AZ 86005-2701 PH: 928-226-4219 FAX: 928-226-4110 finaid@coconino.edu
FA-104 DVWS20 20190312
Instructions for Section B:
SECTION B. Tax Status and Requirements for Student: Check the box below that applies.
Student filed 2017 Federal Income taxes and used the IRS Data Retrieval Tool to transfer in the 2017 IRS
income information onto the FAFSA. Skip to Section C.
Student did not use the IRS Data Retrieval Tool on the FAFSA but did file 2017 Federal Income taxes.
Student must attach an official 2017 IRS Tax Return Transcript. Skip to Section C.
Student worked but was not required to file 2017 Federal Income Taxes. Complete the chart below AND
attach copies of your 2017 W-2’s. Also attach an IRS Non-Filing Letter for the 2017 tax year.
Employer(s) in 2017
2017 Income
$
$
$
Student did not work in 2017 and is not required to file a tax return.
Instructions for Section C:
SECTION C. Tax Status and Requirements for Parent(s): If you were required to report parent(s) information on the
FAFSA, check the box below that applies.
Parent(s) filed 2017 Federal Income taxes and used the IRS Data Retrieval Tool to transfer in the 2017 IRS
income information onto the FAFSA. Skip to Section D.
Parent(s) did not use the IRS Data Retrieval Tool on the FAFSA but did file 2017 Federal Income taxes.
Spouse must attach an official 2017 IRS Tax Return Transcript. Skip to Section D.
Parent(s) worked but was not required to file 2017 Federal Income Taxes. Complete the chart below AND
attach copies of your spouse’s 2017 W-2’s. Also attach an IRS Non-Filing Letter for the 2017 tax year.
Employer(s)
2017 Income
$
$
$
Parent(s) did not work in 2017 and are not required to file 2017 Federal Income Taxes. Attach a copy of
the IRS Non-Filing Letter for the 2017 tax year.
Explain how your parent(s) financially supported their household in 2017.
SECTION D. Sign this Worksheet
Each person signing this form certifies that all the information reported on it is complete and correct. The student and at least
one parent must sign this form. If the student’s parents are separated / divorced, the parent whose information is on the FAFSA
must sign. I certify that information provided on this form is true and complete to the best of my knowledge. Purposely giving
false or misleading information may result in a delay or denial of my federal financial aid and I may be fined up to $20,000, sent
to prison or both.
Student Date Parent (Required for dependent students) Date
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FA103 DVWS20 (Coconino Community College)

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Completed 25 July 2020

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