Fillable Form must be completed in blue or black (Lamar Community College)

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Form must be completed in blue or black (Lamar Community College)

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VWI5E
2019-20 Verification Worksheet for Independent Student – Form 5
Student ID Number: S
Student Name:
Phone Number:
Form must be completed in blue or black ink. Failure to accurately complete this form may result in a delay
of processing or change of financial aid eligibility. Additional documentation may be requested. Read
instructions carefully before completing.
Section 1: High School Completion Status
Please submit documentation to verify you have completed a high school education. Acceptable
documentation can include:
• A high school diploma or a copy of an official high school transcript. Transcripts must verify graduation
completion date
• GED certificate or transcrip
t
• A
transcript that indicates that you have successfully completed at least a two-year program that is acceptab
le
fo
r full credit toward a bachelor’s degree at any participatingschoo
l
• Home school credential ortranscript
• If h
igh school completed in foreign country, a copy of the “secondary school leaving certificate” or sim
ilar
d
ocumen
t
Type of documentation submitted:
Designated institutional official:
(School official’s printed name)
Section 2: Identity
MUST BE COMPLETED & SIGNED AT THE FINANCIAL AID OFFICE
If unable to appear in person at the Financial Aid Office, you must complete this section with a notary
You must appear in person at Financial Aid Office to verify your
(Name of institution)
identity by presenting a valid unexpired government-issued photo identification (ID), such as, but not limited
to, a driver’s license, other state-issued ID, or passport. The institution will maintain a copy of your photo ID.
Type of documentation submitted:
Designated institutional official:
(School official’s printed name)
Page 1 of 4
VWI5E
Student ID Number: S
Section 3: Statement of Educational Purpose
MUST BE COMPLETED & SIGNED AT THE FINANCIAL AID OFFICE
If unable to appear in person at the Financial Aid Office, you must complete this section with a notary
In addition, you must sign, in the presence of the institutional official, the following:
I certify that I am the individual signing this
(Student’s printed name)
Statement of Educational Purpose and that the federal student financial assistance
I may receive will only be used for educational purposes and to pay the cost of attending
for 2019-2020.
(Name of institution)
Student Signature: Date:
Notary Section Instructions: Please Read
This section should only be completed if you are unable to appear in person at the institution with a designated official.
This form (the original on which the seal is visible) should be mailed to the Financial Aid Office at your institution along
with the copy of the government-issued identification and high school documentation.
Notary’s Certificate of Acknowledgement
State of City/County of
On
, before me
(Date) (Notary’s name)
Personally appeared
and proved to me on the basis of
(Printed name of signer)
Satisfactory evidence
of Identification to be the above-named
(Type of unexpired government-issued ID provided)
Person who signed the foregoing instrument.
My commission expires on , 20
Notary (Print):
Notary (Signature):
Page 2 of 4
VWI5E
Student ID Number: S
Section 4: Household Information
Student Information
List the people in your household, including:
• Yourself (the ‘student’), and your spouse if you were married when you signed the FAFSAand
;
• Y
our dependent children, if you will provide more than half of their support * from July 1, 2019 through J
une
30,
2020, even if they do not live with you, and
;
• O
ther people if they live with you, and you provide more than half of their support* and will continue
to
p
rovide more than half of their support from July 1, 2019 through June 30, 2020
.
*Support includes money, gifts, loans, housing, food, clothes, car, medical/dental care, college tuition, etc.
Full Name
Age
Relationship to
Student
The name of the college attending from July 1, 2019 to
June 30, 2020. Must attend at least ½ time and be
enrolled in an eligible degree and/or certificate.
Self
THIS SPACE INTENTIONALLY
LEFT BLANK
Page 3 of 4
VWI5E
Student ID Number: S
Section 5: Income Information
• TAX FILERS:
o If you and your spouse filed a 2017 Federal Income Tax Return, you must either give the Internal Revenue Service
(IRS) permission to transfer all 2017 tax information directly to the FAFSA through the IRS Data Retrieval Tool, or
submit a 2017 Federal Tax Return Transcript, or signed 2017 Federal Tax Return.
o To obtain an IRS Federal Tax Return Transcript, you may go to https://www.irs.gov/individuals/get- transcript and
click on “Get a Transcript Online” or “Get a Transcript by Mail” or call 1-800-908-9946. Be sure to order the IRS Tax
“Return” Transcript. If you and your spouse did not file 2017 taxes jointly, both you and your spouse should
submit a Tax Return Transcript.
• NON-TAX FILERS:
o If you and/or your spouse did not file a 2017 Federal Income Tax Return, you are required to submit a
Statement of Non-Filing and all 2017 W2s. To receive a 2017 Statement of Non-Filing, go to https://www.irs.gov/
pub/irs- pdf/f4506t.pdf and complete Form 4506-T with Box 7 checked. If you are unable to obtain a Statement of
Non-Filing, please contact the Financial Aid Office.
o If you (the student) or your spouse are not able to locate your 2017 W2s, you can request to receive your Wage
and Income Statement by checking Box 8 on the 4506-T.
2017 Tax Filing Status: Only select one option for each individual
Student Spouse
1. Has used or plans to use the IRS Data Retrieval Tool to transfer tax information
electronically on FAFSA.
☐
☐
2. Has or plans to submit a copy of their 2017 IRS Federal Tax Return
Transcript or signed 2017 IRS Federal Tax Return.
☐
☐
3. Has not filed, was not required to file, and had no income earned from work in
2017.
☐
☐
4. Has not filed, was not required to file, but had incomeearned from work in
2017 as listed below, and already has or plans to submit all 2017 W2’s. If this
box is selected, wage information must be completed below.
☐
☐
2017 Wage Information (Only Non-Filers)
Only complete wage information for each person who selected Option 4 in the previous chart.
Non-Tax Filer
Name of Employer
2017 Income Earned
Student
$
$
Spouse
$
$
If more space is needed, attach a separate page with student’s name and student ID number.
By signing this document, I certify that the information is complete, true and accurate. I understand that purposely
providing false or misleading information could result in criminal prosecution, a prison sentence, and/or a fine
pursuant to U.S. Criminal Code and Colorado Criminal Code.
Student Signature: Date:
Page 4 of 4
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Completed 25 July 2020

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