_______________________________ ______
2018-2019
Independent Verification Worksheet
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 Cal
iforni
a Dream Act
App licati
on (AB540 or AB2000) with an IRS 2016
Federal Tax Return Transcript, information from this form, and other documents provided by you and your pare
n
ts. 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 who will be attending College at least half
---
time between July 1
s t
201
8
andJune 30
th
, 2019.
First and Last Name of Family Member Age Relationship to Student
College Attending 18
---
19
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 2016
Federal IRS Tax Return T
ranscript OR an IRS Verification of Non-Tax Filer Letter
call the IRS at
1-800-908-9946 or go to http://www.irs.gov/Individuals/Order-a-Transcript .
Student
Spouse
__ I filed a 2016 1040 tax return and used the IRS Data Retrieval Tool
_
I filed a 2016 1040 tax return and have attached my IRS Tax Transcript
I was employed in 2016 but am not required to file a 1040
A IRS Ver. Non-Tax Filers Letter is required along with W- 2 forms
I was not employed and had zero income from work in
2016
A IRS Verification of Non-Tax Filing Letter is required
I filed a 2016 1040 tax return and used the IRS Data Retrieval
Tool
I filed 2016 1040 t
ax return and have attached my IRS Tax
Transcript
I was employed in 2016 but am not required to file a 1040
A IRS Ver. Non-Tax Filing Letter is required along with W-2 forms
I was not employed and had zero income from work 2016
A
IRS Verificiation of Non-Tax Filing Letter is required
C. Untaxed Income and Benefits
Indicate the untaxed income received in 2016 and the amount. This can include money you and/or your spouse 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 Signature
1570 East Colorado Blvd., Pasadena, California 91106
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2003 19INDV
