2021-2022 Verification Worksheet for Independent Student Form 1
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: Household Information
Student Information
List the people in your household, including:
Yourself (the ‘st
udent’), and your spouse if you were married when you signed the FAFSA and;
Your dependent children, if you will provide more than half of their support * from July 1, 2021
through June 30, 2022, even if they do not live with you, and;
Other people if they live with you, and you provide more than half of their support* and will continue to
provide more than half of their support from July 1, 2021 through June 30, 2022.
Family Information
*Support includes money, gifts, loans, housing, food, clothes, car, medical/dental care, college tuition, etc.
Full Name
Relationship to
The name of the college attending from July 1, 2021
to June 30, 2022 and will be enrolled in at least half-
time , in an eligible degree and/or certificate program.
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Student ID Number: S
Section 2: Income Information
If you and your spouse filed a 2019 Federal Income Tax Return, you must either give theInternal RevenueService (IRS)
permission to transfer all 2019 tax information directly to the FAFSA through the IRS Data RetrievalTool, or submit a
2019 Federal Tax Return Transcript, or a signed copy of the 2019 Federal Tax Return with all applicable schedules.
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” orGet 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 2019 taxes jointly, both you and your spouse should submit a Tax Return
If you and/or your spouse did not file a 2019 Federal Income Tax Return,you are required to submit a Statement of Non-
Filing and all 2019 W2s. To receive a 2018 Statement of Non-Filing, go to https://www.irs.gov/pub/irs-pdf/f4506t.pdf
complete form 4506-T with Box 7 checked. If you are unable to obtain the Statement of Non-Filing, please contact the
Financial Aid Office.
If you (the student) or your spouse are not able to locate your 2019 W2s, you can request to receive your Wage and
Income Statement by checking Box 8 on the 4506-T.
2019 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, or has plans t
o submit a copy of their 2019 IRS Federal Tax
Return Transcripts or signed 2019 IRS Federal Return with all applicable schedules.
2. Had income earned from work in 2019 as listed below, but has not filed and was not required
o file a tax return and already has or plans to submit all 2019 W2's & 1099's.
If this box is selected; 2019 wage information must be completed below.
3. Had no income, will not file, and was not required to file, a 2019 IRS Income Tax Ret
2019 Wage Information (Only Non-Filers
Only complete wage information for each person who selected Option 2 in the previous chart.
Non-Tax Filer Name of Employer 2019 Income Earned
If more space is needed, attach a separate page with students name andstudent 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:
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