Fillable Independent Dream V1 (California State University Channel Islands)

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Independent Dream V1 (California State University Channel Islands)

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FA-25 / 18-19 Page 1 of 3
2018-2019 Dream Act Application
Independent Verification Worksheet
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
Student Last Name
Student First Name
CSUCI ID Number
Student Phone Number
DO NOT SUBMIT THIS FORM UNLESS IT WAS REQUESTED BY OUR OFFICE
Purpose
Your 2018-2019 Dream Act Application was selected for review in a process called verification. You must complete and sign this worksheet, attach
any required documents, and submit the form and other required documents to the Financial Aid & Scholarships office. We may also ask for
additional information upon further review. If you have special circumstances or require further instructions, please contact our office at
financial.aid@csuci.edu or (805) 437-8530.
A. Household Information
1. Complete the following information about yourself and your spouse (if applicable)
First and Last Name
Age
Relationship to Student
Name of College student will attend in 2018-2019*
Self
CSU Channel Islands
Spouse
2. Do you have any children that you will provide more than half of their support from July 1, 2018 through June 30, 2019 (even if they do not live
with you)?
Yes (complete the chart below)
No (skip to next question)
First and Last Name
Age
Relationship to Student
Name of College student will attend in 2018-2019*
Child
Child
Child
Child
3. Are there any other people who live with you (e.g. grandparents, siblings, etc.) and who you will provide more than half of their support from
July 1, 2018 through June 30, 2019?
Yes (complete the chart below)
No (skip to next section)
First and Last Name
Age
Relationship to Student
Name of College relative will attend in 2018-2019*
* 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, 2018 and June 30, 2019. If more space is needed, attach a separate page with student's name and CI ID# at the top.
Acceptable Documentation for Taxable Income
If you filed a 2016 income tax return, then you are required to submit your 2016 IRS Tax Return Transcript to the Financial Aid & Scholarships
office as part of the verification requirements. Person(s) who use an Individual Taxpayer Identification Number (ITIN) instead of a Social Security
Number to file taxes may only request a transcript by using the "Get Transcript by Mail" option on www.irs.gov/transcript.
Do NOT email any IRS Tax Return Transcripts or other IRS documents (i.e. Form W-2, Form 4868, Verification of Non-filing Status, etc.) to our
office unless you securely encrypt the email attachments. For more information on encryption and data security, visit our website at
www.csuci.edu/financialaid/data-security.
FA-25 / 18-19 Page 2 of 3
2018-2019 Dream Act Application
Independent Verification Worksheet
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
B. Student's Income Information
Did, or will, you, the student, file a 2016 income tax return with the IRS?
Yes (select one option from column below)
No (select one option from column below)
Student Tax Filers
Student Nontax Filers
I have already filed
Submit your 2016 IRS Tax Return Transcript*
I was not employed and had no income earned from work in
2016
Submit Verification of Non-filing for 2016*
I will file, but have not yet completed my return because I have
been approved for an extension beyond the October 2017
deadline
Submit Verification of Non-filing for 2016*
Submit a copy of your 2016 IRS Form 4868
Submit a copy of a letter from the IRS confirming you were
approved for an extension beyond six months
Submit a copy of all your 2016 Form W-2(s) from your
employers or a 2016 IRS Wage and Income Transcript*
If you were self-employed, submit a typed and signed
statement (use the "Financial Aid Statement Form") with the
amount of your 2016 Adjusted Gross Income (AGI) and
estimated U.S. income taxes paid
I was employed in 2016
Submit Verification of Non-filing for 2016*
Submit a copy of all your 2016 Form W-2(s) from your
employers or your 2016 IRS Wage and Income Transcript*
List the names of all your employer(s) and the amount
earned from each employer in 2016
Employer's Name
2016 Amount
Earned
Example:
Suzy’s Auto Body Shop
Example:
$2,000.00
If you are unable to provide the documents please contact our
office for further instruction.
* For further instruction, refer to the IRS Tax Transcript Information sheet found on our website at www.csuci.edu/financialaid/financial-aid-forms
Student's Marital Status
What was your marital status on the day you first submitted your 2018-2019 Dream Act Application?
Single
Married/Remarried (complete section C)
Separated
Divorced or Widowed
Student & Spouse Marital and Tax Filing Status
Check the appropriate box: (for informational purposes only)
Marital status is “Married/Remarried” and your tax filing status for 2016 was “Married Filing Jointly”
You must attach a copy of your 2016 IRS Tax Return Transcript
Marital status is “Married/Remarried” and your tax filing status for 2016 was “Married Filing Separately”
You must attach a copy of BOTH your and your spouse's 2016 IRS Tax Return Transcripts
Marital status is “Separated” or “Divorced or Widowed” and your tax filing status for 2016 was “Married Filing Jointly”
You must attach a copy of your 2016 IRS Tax Return Transcript AND copies of all your 2016 Form W-2(s)
None of these options apply
FA-25 / 18-19 Page 3 of 3
2018-2019 Dream Act Application
Independent Verification Worksheet
PLEASE RETURN THIS FORM TO THE CSU CHANNEL ISLANDS FINANCIAL AID & SCHOLARSHIPS OFFICE
One University Drive, Camarillo, California 93012-8599 financial.aid@csuci.edu www.csuci.edu/financialaid Tel: (805) 437-8530
C. Spouse’s Income Information (Complete if Married/Remarried)
Did, or will, your spouse file a 2016 income tax return with the IRS?
Yes (select one option from column below)
No (select one option from column below)
Spouse Tax Filers
Spouse Nontax Filers
My spouse has already filed
Submit your spouse’s 2016 IRS Tax Return Transcript*
My spouse was not employed and had no income earned from
work in 2016
Submit your spouse’s Verification of Non-filing for 2016*
My spouse will file, but they have not yet completed their
return because they have been approved for an extension
beyond the October 2017 deadline
Submit your spouse’s Verification of Non-filing for 2016*
Submit a copy of your spouse’s 2016 IRS Form 4868
Submit a copy of a letter from the IRS confirming your
spouse was approved for an extension beyond six months
Submit a copy of all your spouse’s 2016 Form W-2(s) from
their employers or your spouse’s 2016 IRS Wage and
Income Transcripts*
If your spouse was self-employed, submit a typed and signed
statement (use the "Financial Aid Statement Form") with the
amount of their 2016 Adjusted Gross Income (AGI) and
estimated U.S. income taxes paid
My spouse was employed in 2016
Submit your spouse’s Verification of Non-filing for 2016*
Submit a copy of all your spouse’s 2016 Form W-2(s) from
their employers or your spouse’s 2016 IRS Wage and
Income Transcripts*
List the names of all your spouse’s employer(s) and the
amount earned from each employer in 2016
Employer's Name
2016 Amount
Earned
Example:
Alfred’s Auto Body Shop
Example:
$2,000.00
If you are unable to provide the documents please contact our
office for further instruction.
* For further instruction, refer to the IRS Tax Transcript Information sheet found on our website at www.csuci.edu/financialaid/financial-aid-forms
D. Untaxed Income Information
1. In 2016, did you or your spouse have any untaxed portions of an IRA
Distribution(s) that was a rollover?
2. In 2016, did you or your spouse have any untaxed portions of a
Pension(s) Distribution(s) that was a rollover?
Yes… Total rollover amount for 2016: $
Yes … Total rollover amount for 2016: $
No
No
E. Certification and Signature
The student must sign and date below. If married, the spouse's signature is optional. Each person signing this worksheet certifies that all of the
information reported on this form is true and accurate to the best of their knowledge.
WARNING:
If you purposely give false or
misleading information on this
form, you may be fined, sentenced
to jail, or both.
Student’s Signature (electronic signatures not accepted)
Date
Spouse’s Signature (electronic signatures not accepted)
Date
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Independent Dream V1 (California State University Channel Islands)

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Completed 23 July 2020

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