2021-2022 Verification Worksheet for Dependent Student Form 1
Student ID
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/Parent(s) Information
List the people in your household, including:
Yourself (thestudent’), andyour parent(s);
Your parents’ other children, even if they don’t live with your parent(s), if (a) your parents will provide more
than half of their support* from July 1, 2021 through June 30, 2022, or (b) the children would be required to
provide parental information if they were completing a FAFSA for2021-2022, and;
Other people if they live with yourparent(s), andyour parent(s) providemore than half of their support* and will
continue to provide more than half of their support from July 1, 2021throughJune 30, 2022.
Family Information
*Support includes money, gifts, loans, housing, food, clothes, car, medical/dental care, college tuition, etc.
Full Name Age 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
Section 2: Income Information
o If you and/or your parent(s) filed a 2019 Federal Income Tax Return, you must either give the Internal Revenue
Service (IRS) permission to transfer all 2019 tax information directly to the FAFSA through the IRS Data Retrieval
Tool (DRT), or submit a 2019FederalTaxReturnTranscript, or a signed copy of the 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 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 there are two parents listed on your FAFSA and they didnot file 2019taxes jointly,
both parents listed on the FAFSA should submit a Tax Return Transcript.
o If your parent(s) did not file a 2019 Federal Income Tax Return, they are required to submit a Statement of
Non-Filing and all 2019 W2s. To obtain a 2019 St
atement 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 the Statement of Non-Filing,
contact the Financial Aid Office.
o If you (the student) or your parent(s) 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 Parent
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
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 eachpersonwho selected Option2 in the previous chart.
Non-Tax Filer Name of Employer 2019 Income Earned
If more space is needed, attach a separate page with student’s 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:
Parent Signature:
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