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Independent
OFFICE OF FINANCIAL AID
2019-2020 Verification Worksheet
Your Free Application for Federal Student Aid (FAFSA) was selected
for a “Verification” process which compares information from your
FAFSA with your (and your spouse’s, if you are married) 2017
Federal income tax information and/or other financial documents.
Based on this review, Purdue University Northwest may need to
make electronic corrections to your FAFSA information.
Verification must be completed by Sept. 30, 2020 or 120 days after
your last day of enrollment for 2019-2020, whichever is earlier.
Verification includes receipt of a valid and correct Institutional
Student Information Record (ISIR) with an official Expected Family
Contribution (EFC). Financial aid will not be disbursed until the
verification process is complete.
Federal Law requires Purdue University Northwest to review the requested
information under the financial program rule 34CFR, Part 668
What you should do
1. Complete, sign and submit this Verification Worksheet.
2. Submit your (and your spouse’s) 2017 IRS Tax Return
Transcript(s), if required, and any other requested documents
to the Office of Financial Aid. IRS Tax Return Transcripts may
be requested from the IRS on-line at www.irs.gov or by calling
1-800-908-9946.
3. If the student and/or spouse, filed or will file, an Amended 2017
IRS Tax Return, contact the Office of Financial Aid at Purdue
University Northwest.
Note: Deadline for submitting verification information is September 1, 2019.
Eligibility for financial aid will not be determined until verification is complete.
SECTION 1: To be completed by all students.
A. Student Information
Last Name First MI PUID
Address (include apt. no.) Date of Birth (month/day/year)
City State ZIP code Phone Number (include area code)
E-Mail Address Cell Phone Number (include area code)
B. Family Information
List the people in your household, include:
Yourself, and your spouse if you have one.
Your children, if you will provide more than half of their support from July 1, 2019 through June 30, 2020, even if they
did not live with you.
Other people if they now 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, 2019 through June 30, 2020.
Write the names of all household members in the space(s) below. Also write in the name of the college for any household
member who will be attending college at least half-time between July 1, 2019 through June 30, 2020 and will be enrolled in
a degree, diploma, or certificate program. If you require additional space, please attach a separate page.
Full Name Age Relationship College
Self Purdue University Northwest
(Over)
Hammond Campus
2200 169th Street * Hammond, IN 46323
(219)) 989-2301 * FAX: (219) 989-2141
Westville Campus
1401 S. U.S. Hwy. 421 * Westville, IN 46391
(219) 785-5460
* FAX: (219) 785-5653
Toll-Free: 1-855-608-4600
website: pnw.edu
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Independent
SECTION 2: Complete this section ONLY IF you did NOT transfer your 2017 tax information directly
from the IRS to your FAFSA when completing your FAFSA online OR you made changes to the information
transferred from the IRS.
A. Student’s Tax Information: (Check only one box below)
Check here and attach your 2017 IRS Tax Return Transcript. A Tax Return Transcript may be requested from the
Internal Revenue Service online at www.irs.gov or by calling 1-800-908-9946. And, if you filed an Amended
Income Tax Return, you must also attach a signed copy of your 2017 IRS Form 1040X that was filed with the IRS.
Check here if you will not file and are not required to file a 2017 Federal tax return. You must attempt to
retrieve your IRS Tax Return Transcript and provide the document with the resulting message
from the IRS that states you did not file a return for 2017.
(Note: If you did not file and are not required to file a 2017 Federal tax return, list below your employer(s) and
any income you received in 2017. Attach copies of all 2017 W-2 forms and other earnings statements
for each source of income received in 2017.)
Sources of Income and / or Child Support
2017 Amount
$
$
$
B. Spouse’s Tax Information: (Check only one box below)
Check here, and attach spouse’s 2017 IRS Tax Return Transcript. A Tax Return Transcript may be requested from the
Internal Revenue Service online at www.irs.gov or by calling 1-800-908-9946. And, if your spouse filed an Amended
Income Tax Return, you must also attach a signed copy of your spouse’s 2017 IRS Form 1040X that was filed with the
IRS
Check here if your spouse will not file and is not required to file a 2017 Federal tax return. Spouse must attempt to
retrieve his/her IRS Tax Return Transcript and provide the document with the resulting message from
the IRS that states he/she did not file a return for 2017.
(Note: If your spouse did not file and was not required to file a 2017 Federal tax return, list below your spouse’s
employer(s) and any income spouse received in 2017. Attach copies of all 2017 W-2 forms and other earnings
statements for each source of income spouse received in 2017.)
Sources of Income and / or Child Support
2017 Amount
$
$
$
SECTION 3: Sign this Verification Worksheet
By signing this Verification Worksheet, I (we) certify that all information
WARNING: If you purposely give false or misleading
reported on it is complete and correct.
information on this Verification Worksheet you may
If married, spouse’s signature is optional.
be fined, be sentenced to jail, or both.
Student’s Signature Date
Spouse’s Signature
(optional) Date
Do not mail this worksheet to the U. S. Department of Education. Submit this worksheet, along with all IRS Tax Return Transcript(s),
if required, and any other requested documents to the Office of Financial Aid at Purdue University Northwest.
Office Use Only - RRAAREQ: _____IVER20 (R) _____ STRN20 (C/R) ____ SW2-20(R) _____ STRX20 (R)
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