Verification of 2017 Income
Information / Individual’s
Unusual Circumstances
Please Type or Print clearly in BLUE or BLACK ink
Federal Student Aid Programs: Your application was selected for review in a process called “Verification. In this process, the Office of
Financial Aid will be comparing information from your application with your (and your parent(s), if a dependent student or your spouse, if an
independent student) financial documents. We are required to review your FAFSA information under financial aid program rules (34 CFR, Part
668). The law states we have the right to ask you for this information before awarding Federal Aid. If there are differences between your application
information and your financial documents, corrections to your FAFSA may be required.
Student Information
______________________________________________________ ________________________________
Student’s Last Name Student’s First Name Student’s M.I. Southern Crescent Student ID #
____________________________________________________________
Student’s Street Address (include apt. no.) Student’s Date of Birth
____________________________________________________________
City State Zip Code Student’s Email Address
____________________________________________________________
Student’s Home Phone Number (include area code) Student’s Alternate or Cell Phone Number
Please check the Unusual Circumstance that applies to you and submit all listed documents.
_____Individuals Granted a Filing Extension by the IRS
If an individual is required to file a 2017 IRS income tax return and has been granted a filing extension by the
IRS, provide the following documents:
A copy of IRS Form 4868, ‘‘Application for Automatic Extension of Time to File U.S. Individual Income
Tax Return,’’ that was filed with the IRS for tax year 2017;
A copy of the IRS's approval of an extension beyond the automatic six-month extension if the individual
requested an additional extension of the filing time for tax year 2017; and
A copy of IRS Form W–2 for each source of employment income received for tax year 2017 and, if self-
employed, a signed statement certifying the amount of the individual’s Adjusted Gross Income (AGI) and the
U.S. income tax paid for tax year 2017.
Office of Financial Aid
501 Varsity Road 1533 Hwy 19 South
Griffin, GA 30223 Thomaston, GA 30286
770-228-7368 p 706-646-6386 p
770-229-3029 f 706-646-6063 f
Student’s
Name:
SSN:
_____Individuals Who Filed an Amended IRS Income Tax Return
If an individual filed an amended IRS income tax return for tax year 2017, provide both of the following:
A signed copy of the original 2017 IRS income tax return that was filed with the IRS or a 2017 IRS Tax
Return Transcript of the 2017 tax year; and
A signed copy of the 2017 IRS Form 1040X, “Amended U.S. Individual Income Tax Return,” that was filed
with the IRS.
_____Individuals Who Were Victims of IRS Identity Theft
A victim of IRS identity theft who is not able to obtain a 2017 IRS Tax Return Transcript or use the IRS
DRT must contact the IRS at 1-800-908-4490. Upon authentication of the tax filer’s identity, the IRS will
provide, by U.S. Postal Service, a printout of the tax filer’s 2017 IRS income tax return information.
A signed and dated statement from the tax filers that they are victims of IRS tax-related identity theft and
that the IRS has been made aware.
_____Individuals Who Filed Non-IRS Income Tax Returns
An individual filed or will file a 2017 income tax return with Puerto Rico, another U.S. territory (e.g., Guam,
American Samoa, the U.S. Virgin Islands, the Northern Marianas Islands), or with a foreign country, must
provide a signed copy of that 2017 income tax return(s).
Certification and Signature
WARNING: If you purposely give false or misleading
information on this worksheet, you may be fined, be
sentenced to jail, or both.
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Student’s Signature Date
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Spouse’s Signature Date
Please submit this worksheet to the Office of Financial Aid!
As set forth in full in the Student Handbook/Course Catalog, Southern Crescent Technical College is an Equal Opportunity Institution and does not discriminate on the basis of race, color,
national origin, sex, age or disability.
Each person signing below certifies that all of the information
reported in this worksheet is complete and correct. They must
sign this worksheet. If married, the spouse signature is
optional.
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signature
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signature
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