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
B. Student's Family Information (Dependent Student)
Full Name Age Relationship College
Will Be Enrolled at Least Half Time
Missy Jones (example) 18 Sister Central University Yes
Self
Polytechnic University of Puerto Rico
Single (never married) Married (includes remarried) Separated/Divorced
Unmarried and both parents living together
Widowed
V5
Dependent Student Independent Student
B. Student's Information (Independent Student)
Number of Household Members: List below the people in the student's household. Include:
The student.
The student's spouse, if the student is married.
The student's or spouse's children if the student or spouse will provide more than half of the children's support
from July 1, 2016, through June 30, 2017, even if a child does not live with the student.
Other people if they now live with the student and the student or spouse provides more than half of the other
person's support, and will continue to provide more than half of that person's support through June 30, 2017.
Number in College: Include in the space below information about any household member who is, or will be,
enrolled at least half time in a degree, diploma, or certificate program at an eligible postsecondary educational
institution any time between July 1, 2016, and June 30, 2017, include the name of the college.
If more space is needed, provide a separate page with the student's name and ID number at the top.
Student Marital status:
Number of Household Members: List below the people in the parents' household. Include:
The student.
The parents (including a stepparent) even if the student doesn't live with the parents.
The parents' other children if the parents will provide more than half of the children's support from July 1, 2016,
through June 30, 2017, or if the other children would be required to provide parental information if they were
completing a FAFSA for 2016 -2017. Include children who meet either of these standards, even if a child does
not live with the parents.
Other people if they now live with the parents and the parents provide more than half of the other person's
support, and will continue to provide more than half of that person's support through June 30, 2017.
Number in College: Include in the space below information about any household member who is, or will be,
enrolled at least half time in a degree, diploma, or certificate program at an eligible postsecondary educational
institution any time between July 1, 2016, and June 30, 2017, include the name of the college.
If more space is needed, provide a separate page with the student's name and ID number at the top.
Parent(s) marital status:
Single (never married) Married (or remarried) Separated Divorced/Wdowed
C. Student's Income Information to Be Verified:
1. TAX RETURN FILERS - Important Note: The instructions below apply to the student (and spouse, if married).
Instructions: Complete this section if the student and spouse filed or will file a 2015 IRS income tax return(s). The best way to verify income is by using the IRS Data Retrieval Tool (IRS DRT) that is part of FAFSA
on the Web at FAFSA.gov. In most cases, no further documentation is needed to verify 2015 income information that was transferred into the student's FAFSA using the IRS DRT if that information was not changed
by the FAFSA filer.
Check the item that applies:
The 2015 Puerto Rican Tax Return will be provided later.The 2015 Puerto Rican Tax Return is provided.
The 2015 IRS Tax Return Transcript(s) will be provided later.The 2015 IRS Tax Return Transcript(s) is provided.
The student has used the IRS DRT in FAFSA on the Web to transfer 2015 IRS income tax return information into the student's FAFSA.
The student has not yet used the IRS DRT in FAFSA on the Web, but will use the tool to transfer 2015 IRS income tax return information into the student's FAFSA once the 2015 IRS income tax
return has been filed.
The student is unable or chooses not to use the IRS DRT in FAFSA on the Web, and instead will provide the school with a 2015 IRS Tax Return Transcript(s).
The student is a Puerto Rican resident and filed or will file a Puerto Rican tax return
2. TAX RETURN NONFILERS - The instructions and certifications below apply to the student and spouse, if the student is married. Complete this section if the student and spouse will not file and are not required to
file a 2015 income tax return with the IRS.
Check the item that applies:
The student was not employed and had no income earned from work in 2015.
The student was employed in 2015 and has listed below the names of all employers, the amount earned from each employer in 2015, and whether an IRS W-2 form is provided. [Provide
copies of all 2015 IRS W-2 forms issued to the student by his/her employers]. List every employer even if the employer did not issue an IRS W-2 form.
If more space is needed, provide a separate page with the student's name and ID number at the top.
Employer's Name
Annual Amount Earned in 2015
IRS W-2 Provided?
Suzy's Auto Body Shop (example)
$2,000.00(example) Yes(example)
Total Amount of Income Earned from Work:
Note: We may require you to provide documentation from the IRS that indicates a 2015 IRS income tax return was not filed with the IRS.
D. Parent's Income Information to Be Verified:
1. TAX RETURN FILERS - Important Note: The instructions below apply to each parent included in the household.
Instructions: Complete this section if the parents filed or will file a 2015 IRS income tax return(s). The best way to verify income is by using the IRS Data Retrieval Tool (IRS DRT) that is part of FAFSA on the Web at
FAFSA.gov. In most cases, no further documentation is needed to verify 2015 income information that was transferred into the student's FAFSA using the IRS DRT if that information was not changed by the FAFSA
filer.
Check the item that applies:
The 2015 IRS Tax Return Transcript(s) is provided. The 2015 IRS Tax Return Transcript(s) will be provided later.
The parents have used the IRS DRT in FAFSA on the Web to transfer 2015 IRS income tax return information into the student's FAFSA.
The parents have not yet used the IRS DRT in FAFSA on the Web, but will use the tool to transfer 2015 IRS income tax return information into the student's FAFSA once the 2015 IRS income tax
return has been filed.
The parents are unable or choose not to use the IRS DRT in FAFSA on the Web, and instead will provide the school with a 2015 IRS Tax Return Transcript(s).
The parents are Puerto Rican residents and filed or will file a Puerto Rican tax return.
The 2015 Puerto Rican Tax Return is provided. The 2015 Puerto Rican Tax Return will be provided later.
2. TAX RETURN NONFILERS - Important Note: The instructions and certifications below apply to each parent included in the household. Complete this section if the parents will not file and are not required to file
a 2015 income tax return with the IRS.
Check the item that applies:
Neither parent was employed, and neither had income earned from work in 2015.
One or both parents were employed in 2015 and have listed below the names of all employers, the amount earned from each employer in 2015, and whether an IRS W-2 form is
provided. [Provide copies of all 2015 IRS W-2 forms issued to the parents by their employers]. List every employer even if the employer did not issue an IRS W-2 form.
If more space is needed, provide a separate page with the student's name and ID number at the top.
Employer's Name 2015 Amount Earned IRS W-2 Attached?
Suzy's Auto Body Shop (example)
$2,000.00(example) Yes(example)
Total Amount of Income Earned from Work:
Note: We may require you to provide documentation from the IRS that indicates a 2015 IRS income tax return was not filed with the IRS.
E. Parent's and Student's Other Information to Be Verified:
SNAP Benefits
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.
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:
F. Additional Parent/Student Information:
Student Item Parents
Education credits (American Opportunity, Hope or Lifetime Learning tax credits).
IRA Deductions and Payments to self-employed SEP, SIMPLE, Keogh and other qualified plans.
Tax exempt interest income.
Untaxed portions of IRA distributions.
Untaxed portions of pensions.
G. 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.
ou should make a copy of this worksheet for your records.
Rev 2/2016
H. 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.
I. 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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