2016-2017
Verification Worksheet
Your 2016 -2017 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says that, before awarding Federal Student Aid, we may ask you to
confirm the information you reported on your FAFSA. To verify that you provided correct information, we will compare your FAFSA with the information on this institutional verification document
and with any other required documents. If there are differences, your FAFSA information may need to be corrected. If Dependent, you and a parent whose information was reported on the FAFSA
must complete and sign this institutional verification document, attach any required documents, and submit the form and other required documents to us. If Independent, you must complete and
sign this institutional verification document, attach any required documents, and submit the form and other required documents to us. We may ask for additional information. If you have questions
about verification, contact us as soon as possible so that your financial aid will not be delayed.
A. Student's Information
Last Name First Name M.I.
Street Address (include apt. no.) City State Zip Code
ID Number Date of Birth (MMDDYYYY) Email Address Alternate Email Address Home Phone Number Cell Phone Number
V4
Dependent Student Independent Student
B. Parent's and Student's Information to Be Verified:
The student or parents certify that _______________________________________, a member of the student's/parents' household, received benefits from the Supplemental Nutrition Assistance
Program (SNAP) sometime during 2014 or 2015. We may require documentation from the agency that issued the SNAP benefits in 2014 or 2015.
SNAP Benefits
Child Support Paid
If one or both of the parents, or the student and/or spouse, who is a member of the student's household, paid child support in 2015, provide in the space below the names of the persons who
paid the child support, the names of the persons to whom the child support was paid, the names and ages of the children for whom the child support was paid, and the total annual amount of
child support that was paid in 2015 for each child. Note: We may require you to provide additional documentation regarding the child support paid.
Name of Person Who Paid Child Support Name of Person to Whom Child Support was Paid Name and age of Child for Whom Support was paid Annual Amount of Child Support Paid in 2015
Marty Jones
Chris Smith(example)
Terry Jones $6,000.00
Total Amount of Child Support Paid:
C. Certification and Signatures:
Each person signing below certifies that all of the information reported is
complete and correct.
Student's Signature
Parent's Signature
WARNING: If you purposely give false or misleading information on
this worksheet, you may be fined, sent to prison, or both.
Student's ID Number Date
Date
Do not mail this worksheet to the U.S. Department of Education.
Submit this worksheet to the financial aid administrator at your school.
You should make a copy of this worksheet for your records.
Rev 2/2016
D. High School Completion Status:
If Provide one of the following documents to indicate the student's high school completion status when the student begins college in 2016 -2017:
A copy of the student's high school diploma.
For students who completed secondary education in a foreign country, a copy of the “secondary school leaving certificate” or other similar document.
A copy of the student's final official high school transcript that shows the date when the diploma was awarded.
A state certificate or transcript received by a student after the student passed a State-authorized examination that the State recognizes as the equivalent of a high school diploma
(GED test, HiSET, TASC, or other State-authorized examination).
An academic transcript that indicates the student successfully completed at least a two-year program that is acceptable for full credit toward a bachelor's degree.
For a student who was homeschooled in a state where state law requires the student to obtain a secondary school completion credential for homeschooling (other than a high
school diploma or its recognized equivalent), a copy of that credential.
For a student who was homeschooled in a state where state law does not require the student to obtain a secondary school completion credential for homeschooling (other than a
high school diploma or its recognized equivalent), a transcript, or the equivalent, signed by the student's parent or guardian, that lists the secondary school courses the student
completed and includes a statement that the student successfully completed a secondary school education in a homeschool setting.
A student who is unable to obtain the documentation listed above must contact the financial aid office.
E. Identity and Statement of Educational Purpose - (to be signed at the institution):
The student must appear in person at Polytechnic University to verify his or her identity by presenting an unexpired valid government-issued photo identification (ID), such as, but not limited to, a
driver's license, other state-issued ID, or passport. The institution will maintain a copy of the student's photo ID that is annotated by the institution with the date it was received and reviewed, and
the name of the official at the institution authorized to receive and review the student's ID.
In addition, the student must sign, in the presence of the institutional official, the Statement of Educational Purpose provided below.
ID information:
Statement of Educational Purpose
I certify that I __________________________________________________________ am the individual signing this Statement of Educational Purpose and that the Federal student
financial assistance I may receive will only be used for educational purposes and to pay the cost of attending Polytechnic University for 2016-2017.
ID Type:
Passport Driver's License Other:
ID number: Expiration Date:
FA Officer:
FA Officer's Signature Date
Student's Signature
Date Student's ID Number
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