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Your FAFSA application has been selected for a (Clackamas Community College)

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  • 6 check-boxes
  • 72 other fields

Country of origin: US
File type: PDF

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Secure submission of documents can be completed in person, by mail, or fax to:
Office of Financial Aid and Scholarships · Roger Rook Hall · 19600 Molalla Avenue, Oregon City, OR 97045
Phone: 503-594-6082 · Fax: 503-722-5864 · e-mail: finaid@clackamas.edu · www.clackamas.edu
03/02/20 Dp
Page1
2020-2021 Dependent
V5 Aggregate Verification
Worksheet
FAC20V5D
Your FAFSA application has been selected for a process called verification. Please complete all parts of this worksheet and return to the Financial Aid
Office. Notice: incomplete forms may delay processing.
B. Household Information – List the members in your parents’ household. Attach an additional sheet if necessary.
Please include: yourself, even if you don’t live with your parents, your parents/step-parent (if your parent is remarried you must include your step-
parent), your parents’ other children (even if they do not live with your parents), siblings, and individuals who will receive more than half of their
support from your parents between July 1, 2020 and June 30, 2021.
Full Name
Relationship to Student
Age
Enrolled in College
at least half-time
(check one)
Self
☐ Yes
☐ No
Parent/Step parent
[This does not apply to parent/step parent]
Parent/Step parent
[This does not apply to parent/step parent]
Sibling/Other: ______
☐ Yes
☐ No
Sibling/Other: ______
☐ Yes
☐ No
Sibling/Other: ______
☐ Yes
☐ No
C. Tell us about your 2018 tax filing status –
Student’s Filing Status (select only one)
I filed my 2018 return and successfully used the IRS Data
Retrieval Tool via the FAFSA. Tax transcript not required.
I filed my 2018 return and chose not to or, I am unable to
use the IRS Data Retrieval Tool. Submit your 2018 (signed)
Tax Return and Schedules 1, 2 & 3 or Tax Return
Transcript.
I amended my taxes after originally filing my 2018 return
and will submit:
o 2018 (signed) Tax Return and Schedules 1, 2 & 3 or
Tax Return Transcript
o 2018 (signed) IRS 1040X form
I did not and I am not required to file a federal tax return. I
was not employed and earned no income from work in
2018.
I did not and I am not required to file a federal tax return.
In 2018, I earned income from the source(s) listed below:
Employer’s Name
2018 Earned
Amount
IRS W-2/1099
Attached
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Attach all W-2s and/or 1099s issued to you in 2018
*IRS Verification of Non-Filing Letters can be requested online or by checking
box 7 and 8 (if no W-2s provided) on IRS Form 4506-T. Notice: 2018 IRS
Verification of Non-Filing Letters must be dated on or after October 1, 2018.
Parent(s) Filing Status (select only one)
My parent(s) filed their 2018 return and successfully
used the IRS Data Retrieval Tool via the FAFSA. Tax
transcript not required.
My parent(s) filed their 2018 tax return and chose not to
or, were not able to use the IRS Data Retrieval Tool.
Submit parent’s 2018 (signed) Tax Return and Schedules
1, 2 & 3 or Tax Return Transcript.
My parent(s) amended their taxes after originally filing
their return and will submit:
o 2018 (signed) Tax Return and Schedules 1, 2 & 3
or Tax Return Transcript
o 2018 (signed) IRS 1040X form
My parent(s) did not and is/are not required to file a
federal tax return. My parent(s) were not employed and
earned no income from work in 2018. Submit 2018 IRS
Verification of Non-filing Letter
My parent(s) did not and is/are not required to file a
federal tax return. In 2018, my parent(s) income from
the source(s) listed below: Submit 2018 IRS Verification of
Non-filing Letter
Employer’s Name
2018 Earned
Amount
IRS W-2/1099
Attached
☐ Yes
☐ No
☐ Yes
☐ No
☐ Yes
☐ No
Attach all W-2s and/or 1099s issued to your parent(s) in 2018
D. Certification and Signatures – Each person signing this worksheet certifies that all of the information reported on it is complete
and correct. The student and one parent whose information was reported on the FAFSA must sign and date. Warning! If you
purposely give false or misleading information you may be fined, sentenced to jail, or both.
Student Signature: _____________________________________________________ Date: ___________________
Parent Signature: ______________________________________________________ Date: ___________________
This worksheet must be signed and dated to be valid. Electronic and/or digital signatures are not valid.
A. Student Information
Student’s Name: ____________________________ Date of Birth: ___________ CCC ID: ___________________
Secure submission of documents can be completed in person, by mail, or fax to:
Office of Financial Aid and Scholarships · Roger Rook Hall · 19600 Molalla Avenue, Oregon City, OR 97045
Phone: 503-594-6082 · Fax: 503-722-5864 · e-mail: finaid@clackamas.edu · www.clackamas.edu
03/02/20 Dp
Page2
2020-2021 Dependent
V5 Aggregate Verification
Worksheet
FAC20V5D
(Print Student’s Name)
DO NOT COMPLETE THIS SECTION IN ADVANCE
F. Identity and Statement of Educational Purpose (To be signed at the institution)
The student must appear in person at Clackamas Community College 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.
G. Identity and Statement of Educational Purpose (To be signed in the presence of a notary)
If the student is unable to appear in person at Clackamas Community College to verify his or her identity, the student
must provide to the institution:
(a) A copy of the unexpired valid government-issued photo identification (ID) that is acknowledged in the notary
statement below, or that is presented to a notary, such as, but not limited to, a driver’s license, other state-
issued ID, or passport; and
(b) The original Statement of Educational Purpose provided below, which must be notarized. If the notary statement
appears on a separate page than the Statement of Educational Purpose, there must be a clear indication that
the Statement of Educational Purpose was the document notarized.
H. 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 Clackamas Community College for 2020-2021.
________________________________________________________________ _________________
(Student’s Signature) (Date)
_________________________
(Student’s ID Number)
I. Notary’s Certificate of Acknowledgement
State of _______________________________________ City/County of ___________________________________
On_____________________, before me, _____________________________________________, personally appeared,
(Date) (Notary’s name)
____________________________________________________, and provided to me on the basis of satisfactory
(Printed name of signer)
evidence of identification ______________________________________________ to be the above-named person who
(Type of unexpired government-issued photo ID provided)
signed the foregoing instrument.
WITNESS my hand and official seal
(Seal) _________________________________________________
(Notary Signature)
My commission expires on ______________________
This worksheet must be signed and dated to be valid. Electronic and/or digital signatures are not valid.
E. Student Information
Student’s Name: ________________________________________________ CCC ID: _________________________
Secure submission of documents can be completed in person, by mail, or fax to:
Office of Financial Aid and Scholarships · Roger Rook Hall · 19600 Molalla Avenue, Oregon City, OR 97045
Phone: 503-594-6082 · Fax: 503-722-5864 · e-mail: finaid@clackamas.edu · www.clackamas.edu
03/02/20 Dp
Page3
2020-2021 Dependent
V5 Aggregate Verification
Worksheet
FAC20V5D
High School Graduate/Equivalency – Provide one of the following documents to indicate the student’s high school
completion status when the student begins college in 2020-2021:
□ 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.
K. Certification and Signatures – Each person signing this worksheet certifies that all of the information reported
on it is complete and correct. The student and one parent whose information was reported on the FAFSA must
sign and date. Warning! If you purposely give false or misleading information you may be fined, sentenced to jail,
or both.
Student Signature: _____________________________________________________ Date: ___________________
Parent Signature: ______________________________________________________ Date: ___________________
This worksheet must be signed and dated to be valid. Electronic and/or digital signatures are not valid.
J. Student Information
Student’s Name: ________________________________________________ CCC ID: _______________________
NOTE: If there is a difference with your name, please submit documentation such as a marriage
license or court name change document.
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Completed 26 July 2020

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