Verification Worksheet Independent Student- Group 6

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1 Student Financial Services 1200 East Colton Avenue, Redlands, CA Telephone: (909) Fax: (909) Web site: Verification Worksheet Independent Student- Group 6 A. Student s Information Last Name First Name M.I. Redlands ID or SSN Street Address (include apt. no.) City State Zip Code Date of Birth Telephone Number w/ Area Code B. Household Information 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, 2015, through June 30, 2016, even if the children do 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 people s support and will continue to provide more than half of their support through June 30, Number in College: Include below information about, any household member who 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, 2015, and June 30, 2016, include the name of the college. Full Name Age Relationship College Enrolled at Least Half Time (Yes or No) Self C. Student s Income to Be Verified **********ALL 2014 W2 FORMS ISSUED TO THE STUDENT MUST BE SUBMITTED TO OUR OFFICE********** 1. Student Tax Return Filers- STOP. Skip to 2 if you did not or are not required to file a tax return. Instructions: Complete this section if the student filed or will file a 2014 income tax return with the IRS. Check the box that applies: The student has used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and transfer 2014 IRS income information into the student s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA. The school will use the IRS information that was transferred in the verification process. The student has not yet used the IRS Data Retrieval Tool in FAFSA on the Web, but will use the tool to retrieve and transfer 2014 IRS income information into the student s FAFSA once the student has filed a 2014 IRS tax return. Your school cannot complete the verification process until the IRS information has been transferred into your FAFSA. The student is unable or chooses not to use the IRS Data Retrieval Tool in FAFSA on the Web, and the student will submit to the school a 2014 IRS tax return transcript not a photocopy of the income tax return. Verification cannot be completed until the IRS tax return transcript(s) has been submitted to the school.

2 (Section C continued) 2. Student Tax Return Non-Filers- STOP. Skip to Section D if you completed Section 1 on previous page. Instructions: Complete this section if the student will not file and is not required to file a 2014 income tax return with the IRS. Check the box that applies: The student was not employed and had no income earned from work in The student was employed in 2014 and has listed below the names of all the student s employers, the amount earned from each employer in Students who had any income earned from work MUST attach copies of all 2014 IRS W-2 forms issued to the student by employers. List every employer even if they did not issue an IRS W-2 form. Employer s Name 2014 Amount Earned IRS W-2 Attached? D. Student s Other Information to be Verified 1. Child Support Paid- Skip to 2 if this does not apply to you. The student or spouse, who is a member of the student s household, paid child support in List 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 of the children for whom the child support was paid, and the total annual amount of child support that was paid in 2014 for each child. Name of Person Who Paid Child Support Name of Person to Whom Child Support was Paid Name of Child for Whom Support Was Paid Amount of Child Support Paid in SNAP (Food Stamp) Benefits Received- Skip to Section E if this does not apply to you. The student certifies that, a member of the student s household, received benefits from the Supplemental Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program) sometime during 2013 or SNAP may be known by another name in some states. E. Verification of Other Untaxed Income for 2014 *If any item does not apply, enter N/A for Not Applicable where a response is requested, or enter 0 in an area where an amount is requested.* To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in 2014, multiply that amount by the number of months in 2014 you paid or received it. If you did not pay or receive the same amount each month in 2014, add together the amounts you paid or received each month. 1. Payments to tax-deferred pension and retirement savings List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings plans (e.g., 401(k) or 403(b) plans), including, but not limited to, amounts reported on W-2 forms in Boxes 12a through 12d with codes D, E, F, G, H, and S. Name of Person Who Made the Payment Total Amount Paid in Child support received List the actual amount of any child support received in 2014 for the children in your household. Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid. Name of Adult Who Received the Support Name of Child For Whom Support Was Received Amount of Child Support Received in 2014

3 (Section E continued) 3. Housing, food, and other living allowances paid to members of the military, clergy, and others Include cash payments and/or the cash value of benefits received. Do not include the value of on-base military housing or the value of a basic military allowance for housing. Type of Benefit Received Amount of Benefit Received in Veterans non-education benefits List the total amount of veterans non-education benefits received in Include Disability, Death Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances. Do not include federal veteran s educational benefits such as: Montgomery GI Bill, Dependents Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill Type of Veterans Non-education Benefit Amount of Benefit Received in Other untaxed income List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include untaxed income such as workers compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25, Railroad Retirement Benefits, etc. Do not include any items reported or excluded in A D above. In addition, do not include student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels. Type of Other Untaxed Income Amount of Other Untaxed Income Received in Money received or paid on the student s behalf List any money received or paid on the student s behalf in 2014 this is not reported elsewhere on this form. Include support from a parent whose information was not reported on the student s FAFSA, but do not include support from a parent whose information was reported. For example, if someone is paying rent, utility bills, etc., for the student or gives cash, gift cards, etc., include the amount of that person's contributions unless the person is the student s parent whose information is reported on the student s FAFSA. Amounts paid on the student s behalf also include any distributions to the student from a 529 plan owned by someone other than the student or the student s parents, such as grandparents, aunts, and uncles of the student. Purpose: e.g., Cash, Rent, Books Amount Received in 2014 Source

4 (Section E continued) Additional information: So that we can fully understand the student s family's financial situation, please provide below information about any other resources, benefits, and other amounts received by the student and any members of the student s household. This may include items that were not required to be reported on the FAFSA or other forms submitted to the financial aid office, and include such things as federal veterans education benefits, military housing, SNAP, TANF, etc. Type of Financial Support Amount of Financial Support Received in 2014 Please provide a detailed explanation of how you (and/or your spouse) met your family s basic living expenses for F. Certification and Signatures I (We) certify that all information reported on or submitted with this form is complete and correct to the best of our knowledge. I (We) understand that if we purposefully give false or misleading information to qualify for financial aid, I (we) may be subject to prosecution, which may result in a fine, a prison sentence, or both. Student s Signature Spouse s Signature (Optional) Date Date Student Address

5 Verification of 2014 Income Information for Individuals with Unusual Circumstances Individuals Granted a Filing Extension by the IRS If an individual is required to file a 2014 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 2014; 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 2014; and A copy of IRS Form W 2 for each source of employment income received for tax year 2014 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 Individuals Who Filed an Amended IRS Income Tax Return If an individual filed an amended IRS income tax return for tax year 2014, provide both of the following: A signed copy of the original 2014 IRS income tax return that was filed with the IRS or a 2014 IRS Tax Return Transcript; and A signed copy of the 2014 IRS Form 1040X, Amended U.S. Individual Income Tax Return, that was filed with the IRS. Individuals Who Were Victims of Tax Administration Identity Theft A victim of tax administration identity theft who is not able to obtain a 2014 IRS Tax Return Transcript or use the IRS DRT must contact the IRS at Upon authentication of the tax filer s identity, the IRS will provide, by U.S. Postal Service, a printout of the tax filer s 2014 IRS income tax return information. Individuals Who Filed Non-IRS Income Tax Returns An individual filed or will file a 2014 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: o A signed copy of that 2014 income tax return(s); or o A transcript obtained from a government of a U.S. territory or commonwealth, or a foreign central government that includes all of the tax filer s income and tax information required to be verified for tax year 2014.

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