2016-2017 DEPENDENT VERIFICATION WORKSHEET
202 S. Halsted St. | Chicago Heights, IL 60411
Financial Aid Office | (708) 709-3735 |Fax: (708) 709-3716
Your 2016-2017 Free Application for Federal Student Aid (FAFSA)
was selected for review in a process called verification. The law
says that 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.
Until all forms/documents are received, your aid cannot be
processed. If you have questions about verification, contact your
financial aid administrator as soon as possible so that your
financial aid will not be delayed.
Last name First name M.I.
Address (include apt. no.)
City State ZIP Code
ID/Social Security Number Date of Birth Phone number (include area code)
I. Household Information
1. Your parent(s). In cases of separation/divorce, list the parent with whom you lived more during the past 12 months. If this parent is remarried,
you must include your step-parent.
2. Your parent(s) dependents for the 2016-17 academic year. Include yourself and other dependent children.
3. Include other people if they live with you and will receive at least half of their support from your parent(s) during the entire period from July 1,
2016-June 30, 2017.
4. Include the name of the college for any household member who will be enrolled at least half time, in a degree, diploma, or certificate program
at a postsecondary educational institution any time between July 1, 2016, and June 30, 2017. If more space is needed, attach a separate page
with your name and Social Security Number at the top.
Age (as of
12/31/16) Relationship to Student College
Will be Enrolled at
Least Half Time
Self Prairie State College
If you need more space, attach a separate page.
II. Student Tax Form and Income Information
Check only one box below:
The FAFSA was completed using the IRS Data Retrieval tool. No adjustments were made to any of the transferred income information.
The FAFSA could not be completed using the IRS Data Retrieval tool. An official IRS tax transcript for the 2015 tax year will be submitted. To
obtain an IRS tax return transcript, go to www.irs.gov and click on "order a return or account transcript," or call 1 (800) 908-9946.
I will not file and am not required to file a 2015 U.S. Income Tax Return. I am attaching all 2015 W-2(s) for each source of employment income.
I will not file and am not required to file a 2015 U.S. Income Tax Return. Further, I did not receive any 2015 W-2(s). All sources of untaxed
income, if applicable, are listed below.
Sources of Untaxed Income 2015 Amount Employers Name or Other
Sources of Untaxed Income
2015 Income Amount
a. Food Stamps* (SNAP) $ e. $
b. Child Support Received $ f. $
c. Workman’s Compensation $ g. $
d. Untaxed Pensions $ h. $
*In certain situations we may require documentation from the agency that issues the Food Stamps benefit.