2021-2022 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 transcript
Visit www.diplomasender.com if you need a copy of a GED obtained in the State of Colorado.
A transcript that indicates that you have successfully completed at least a two-year program that is acceptable
for full credit towards a bachelor’s degree at any participating school
Home school credential or transcript
If high school is completed in foreign country, a copy of the “secondary school leaving certificate” or similar
document. Foreign High School transcripts may need to be translated and evaluated. For a list of qualified service
providers, please visit www.naces.org/members.
Type of documentation submitted:
Designated institutional official:
(School official’s printed name)
Section 2: Identity
If unable to appear in person at the Financial Aid Office, you must complete this section with anotary
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)
Student ID Number: S
Section 3: Statement of Educational Purpose
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 2021-2022.
(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/Countyof
, before me
(Date) (Notary’s name)
appeared and proved to me on the basis of
(Printed name of signer)
Sati s factory 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):
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Student ID Number: S
Section 4: Household Information
Student Information
List the people in your household, including:
Yourself (thest
udent’), and your spouse if you were married when you signed the FAFSA and;
Your dependent children, if you will provide more thanhalfoftheir 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.
Relationship to
The name of the college attending from July 1, 2021
to June 30, 2022. 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 5: Income Information
o If you and your spouse filed a 2019 Federal Income Tax Return, you either must give the Internal Revenue Service
(IRS) permission to transfer all 2019 tax information directly to the FAFSA through the IRS Data Retrieval Tool, or
submit a 2019 Federal Tax Return Transcript, or signed 2019 Federal Tax Return with all applicable schedules..
o To obtain an IRS Federal Tax Return Transcript, you may go to https://www.irs.gov/individuals/get- transcript and
click onGet 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 Transcript.
o 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 2019 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 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 2019 W2s, youcanrequest 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 to 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 to
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 Return.
2019 Wage Information (Only Non-Filers)
Only complete wage information for eachpersonwho selected Option2 in the previous chart.
Non-Tax Filer Name of Employer 2019 Income Earned
If more spaceis needed, attach a separatepage with student’s name andstudentID number.
By signing this document, I certify that the information is complete, true and accurate. I understand thatpurposely
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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