_______________________________________________________ _______________________________ ______
Independent Verification Worksheet
2017--2018
Student ID
Last Name First Name M.I.
Your application was selected by the US Department of Education for a process called "Verification". In this process, Pasadena City College's (PCC)
Office of Financial Aid will compare information on your FAFSA or your Cal
iforni
a Dr eam Act
Applicati
on (AB540 or AB2000) with an IRS 2015
Federal Tax Return Transcript, information from thisform, and other documents provided by you and your spouse's. Und
e
r the l
aw
,
the college has the right to ask you for this i
nformation before awarding federal and state aid.
A. Family Information
List yourself,your
spouse
, andanyone else you provide more than 50% support for (excluding foster children). Write inthe name of the
college for any householdmember whowill be attending at least half
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time betweenJuly 1
s t
201
7
andJune 30
th
, 2018.
First and Last Name of Family Member Age Relationship to Student College Attending 17
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18
Self Pasadena City College
B. Student and Parent Tax Form
To use the FAFSA
IRS Data Retrieval
Tool
, go to
http://www.FAFSA.gov .
To request a copy of your
Federal IRS Tax Return T
ranscript OR a Non-Tax Filer Statement
call the IRS at
1-800-908-9946 or go to http://www.irs.gov/Individuals/Order-a-Transcript .
Student
Spouse
__ I filed a 2015 1040 tax return and used the IRS Data Retrieval Tool
_
I filed a 2015 1040 tax return and have attached my IRS Tax Transcript
I was employed in 2015 but am not required to file a 1040
Submit W-2 forms
I was not employed and had zero income from work in 2015
I filed a 2015 1040 tax return and used the IRS Data Retrieval
Tool
I filed 2015 1040 tax ret
urn and have attached
my IRS Tax
Transcript
I was employed in 2015 but am not required to file a 1040
Submit W-2 forms
I was not employed and had zero income from work 2015
C. Untaxed Income and Benefits
Indicate the untaxed income received in 2015 and the amount. This can include money you or your spouse’s received from sources in the US or another country. Include all
sources of income used to pay for living expenses including cash support, Veteran’s non
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education benefits, and/or general relief.
Student Spouse
Income from Work (not reported on your 1040) $_________ Income from Work (not reported on your 1040) $_________
Employer_____________________________________ Employer________________________________
Money from Foreign Income $_________ Money from Foreign Income $_________
Money Received on your behalf, other Untaxed Income $_________ Money Received on your behalf, Untaxed Income $_________
Certification: I hereby certify that all information reported on this form and any attachments are true, complete, and accurate. Further, I understand that false statements
and/or misrepresentations will result in denial or reduction, withdrawal, and/or repayment of aid disbursed and student disciplinary action may be taken.
Date
Student's Signature
1570 East Colorado Blvd., Pasadena, California 91106
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2003 18DV1
