VERIFICATION WORKSHEET FOR DEPENDENT STUDENTS FOR V5

Transcription

1 VERIFICATION WORKSHEET FOR DEPENDENT STUDENTS FOR V5 A. Dependent Student s Information Student s Last Name Student s First Name Student s M.I. AU ID# Last 4 digits of SSN Student s Street Address (include apt. no.) Student s Date of Birth City State Zip Code Student s Address Student s Home Phone Number (include area code) Student s Alternate or Cell Phone Number B. Dependent Student s Family Information List below the people in your parent(s) household. Include: Yourself and your parent(s) (including a stepparent) even if you don t live with your parent(s). Your parent(s) other children if your parent(s) will provide more than half of their support from July 1, 2013, through June 30, 2014, or if the other children would be required to provide parental information if they were completing a FAFSA for Include children who meet either of these standards, even if they do not live with your parent(s). Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will continue to provide more than half of their support through June 30, Include the name of the college for any household member, excluding your parent(s), who will be enrolled, at least half time in a degree, diploma, or certificate program at a postsecondary educational institution any time between July 1, 2013, and June 30, If more space is needed, attach a separate page with the student s name and Social Security Number at the top. Full Name Age Relationship College Will be Enrolled at Least Half Time Marty Jones(example) 28 Spouse Central University Yes Self C. Dependent Student s Income Information to Be Verified 1. TAX RETURN FILERS Important Note: If the student filed, or will file, an amended 2012 IRS tax return, the student must contact the financial aid administrator before completing this section. Instructions: Complete this section if the student, filed or will file a 2012 income tax return with the IRS. The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If the student has not already used the tool, go to FAFSA.gov, log in to the student s FAFSA record, select Make FAFSA Corrections, and navigate to the Financial Information section of the form. From there, follow the instructions to determine if the student is eligible to use the IRS Data Retrieval Tool to transfer 2012 IRS income tax information into the student s FAFSA. It takes up to two weeks for IRS income information to be available for the IRS Data Retrieval Tool for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers. If you need more information about when, or how to use the IRS Data Retrieval Tool, please contact the Financial Aid Office.

2 Check the box that applies: The student has used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and transfer 2012 IRS income information into the student s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA. The student s 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 2012 IRS income information into the student s FAFSA once the student has filed a 2012 IRS tax return. See instructions above for information on how to use the IRS Data Retrieval Tool. The student s school cannot complete the verification process until the IRS information has been transferred into the 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 2012 IRS tax return transcript not a photocopy of the income tax return. To obtain an IRS tax return transcript, go to and click on the Order a Return or Account Transcript link, or call Make sure to request the IRS tax return transcript and not the IRS tax account transcript. You will need your Social Security Number, date of birth, and the address on file with the IRS (normally this will be the address used when the 2012 IRS tax return was filed). It takes up to two weeks for IRS income information to be available for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers. Check if the student s IRS tax return transcript is attached to this worksheet. Check if the student s IRS tax return transcript will be submitted to the student s school later. Verification cannot be completed until the IRS tax return transcript has been submitted to the student s school. 2. TAX RETURN NONFILERS Complete this section if the student will not file and is not required to file a 2012 income tax return with the IRS. Check the box that applies (this section continues onto the next page): The student was not employed and had no income earned from work in Please complete this table, listing any sources and amounts of money the student received in 2012 which were used to pay for living expenses. Source of Income 2012 Amount Received Gift from Relative (example) $2, *In addition - if you did not have any source of income in 2012, please attach a statement describing how you met your living expenses in The student was employed in 2012 and has listed below the names of all the student s employers, the amount earned from each employer in 2012, and whether an IRS W-2 form is attached. Attach copies of all 2012 IRS W-2 forms issued to the student by employers. List every employer even if they did not issue an IRS W-2 form. If more space is needed, attach a separate page with the student s name and Social Security Number at the top. Employer s Name 2012 Amount Earned IRS W-2 Attached? Village Kitchen Restaurant (example) $2, Yes

3 Verification of 2012 IRS Income Tax Return Information for Individuals with Unusual Circumstances 3. Income Tax Return Information for Individuals Granted a Filing Extension If you are required to file a 2012 IRS income tax return, and have been granted a filing extension by the IRS, provide the following documents: A copy of the 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 2012; AND A copy of IRS Form W 2 for each source of employment income received for tax year 2012 and, if self-employed, a signed statement certifying the amount of your AGI and the U.S. income tax paid for tax year Income Tax Return Information for Individuals Who Filed an Amended IRS Income Tax Return If you filed an amended IRS income tax return for tax year 2012, provide BOTH of the following: A signed copy of the original 2012 IRS income tax return that was filed with the IRS or a 2012 IRS Tax Return Transcript (signature not required) for the 2012 tax year; AND A signed copy of the 2012 IRS Form 1040X, Amended U.S. Individual Income Tax Return, that was filed with the IRS. 5. Income Tax Return Information for Individuals Who Were Victims of IRS Identity Theft A victim of IRS identity theft who has been unable to obtain a 2012 IRS Tax Return Transcript or use the IRS DRT must provide a signed copy of the 2012 paper IRS income tax return that was filed with the IRS and a signed copy of IRS Form Identity Theft Affidavit if one was submitted to the IRS. If you did not keep a copy of Form or the IRS did not require you to submit one, you may provide one of the following: A statement signed and dated by you indicating that you were a victim of IRS identity theft and that the IRS is investigating the matter. The statement must also indicate that you submitted a Form to the IRS, but did not keep a copy of it or that you were not required to file the form; OR A copy of a police report if it was filed related to the IRS identify theft. 6. Income Tax Return Information for Individuals Who Filed Non-IRS Income Tax Returns If you filed or will file a 2012 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, provide a signed copy of that 2012 income tax return(s). D. All students (regardless of tax filing status) must list any untaxed income received in BE SURE TO ENTER ZEROS IF NO FUNDS WERE RECEIVED. Student s 2012 Additional Financial Information a. Taxable earning from need-based employment programs, such as Federal Work-Study, and need-based $ employment portions of fellowships and assistantships. b. Student grant and scholarship aid reported to the IRS in your adjusted gross income. Includes AmeriCorps $ benefits (awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowship and assistantships. c. Combat pay or special combat pay. Only enter the amount that was taxable and included in your adjusted $ gross income. Do not enter untaxed combat pay reported on the W-2 (Box 12, Code Q). d. Earnings from work under a cooperative education program offered by a college. $

4 E. Student s Untaxed 2012 Income. a. Housing, food and other living allowances paid to members of the military, clergy and others (including $ cash payments and cash value of benefits). b. Veterans non-education benefits such as Disability, Death Pension, or Dependency & Indemnity $ Compensation (DIC) and/or VA Educational Work-Study allowances. c. Other untaxed income not reported, such as worker s compensation, disability, Homebuyer tax credits, etc. $ Don t include student aid, earned income credit, additional child tax credit, welfare payments, food stamps, untaxed Social Security benefits, Supplemental Security income, Workforce Investment Act educational benefits, combat pay, benefits from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion or credit for federal tax on special fuels. d. Money received or bills paid on your behalf (e.g., friend or family member provided housing or other $ support for living expenses), not reported elsewhere on this form. Please describe and explain calculations in this space: F. Parent s Income Information to be Verified Note: If two parents were reported in Section B of this worksheet, the instructions and certifications below refer and apply to both parents. 1. TAX RETURN FILERS Important Note: If the student s parent(s), filed or will file, an amended 2012 IRS tax return the student s financial aid administrator must be contacted before completing this section. Instructions: Complete this section if the student s parent(s) filed or will file a 2012 income tax return with the IRS. The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If the student s parent(s) has not already used the tool, the parent and the student should go to FAFSA.gov, log in to the student s FAFSA record, select Make FAFSA Corrections, and navigate to the Financial Information section of the form. From there, follow the instructions to determine if the parent(s) is eligible to use the IRS Data Retrieval Tool to transfer 2012 IRS income tax information into the student s FAFSA. It takes up to two weeks for IRS income information to be available for the IRS Data Retrieval Tool for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers. If you need more information about whether or how to use the IRS Data Retrieval Tool, please contact the Financial Aid Office. Check the box that applies: The student s parent has used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2012 IRS income information into the student s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA. The student s school will use the IRS information transferred into the student s FAFSA to complete the verification process. The student s parent has not yet used the IRS Data Retrieval Tool, but will use the tool to transfer 2012 IRS income information into the student s FAFSA once the parent s IRS tax return has been filed. See instructions above for information on how to use the IRS Data Retrieval Tool. The student s financial aid administrator cannot complete verification until the parent has transferred IRS information into the student s FAFSA. The parent is unable or chooses not to use the IRS Data Retrieval Tool, and the parent will submit to the student s school a copy of the parent s 2012 IRS tax return transcript(s) not photocopies of the income tax return. To obtain an IRS tax return transcript go to and click on the Order a Return or Account Transcript link, or call Make sure you order the IRS tax return transcript and not the IRS tax account transcript. The parent will need his or her Social Security Number, date of birth, and the address on file with the IRS (normally this will be the address used when the 2012 IRS tax return was filed). It takes up to two weeks for IRS income information to be available for electronic IRS tax return filers, and up to eight weeks for paper tax return filers. If the parents are married, and separate 2012 tax returns were filed, 2012 IRS tax return transcripts must be submitted for each parent. Check here if an IRS tax return transcript(s) is attached to this worksheet. Check here if IRS tax return transcript(s) will be submitted to the student s school later. Verification cannot be completed until the IRS tax return transcript(s) has been submitted to the school.

5 2. TAX RETURN NONFILERS Complete this section if the student s parent(s) will not file and is not required to file a 2012 income tax return with the IRS. Check the box that applies (this section continues onto the next page): The parent(s) was not employed and had no income earned from work in Please complete this table, listing any sources and amounts of money the student received in 2012 which were used to pay for living expenses. Source of Income 2012 Amount Received Gift from Relative (example) $2, *In addition - if your parent(s) did not have any source of income in 2012, please attach a statement describing how they met their living expenses in The parent(s) was employed in 2012 and has listed below the names of all the parent s employers, the amount earned from each employer in 2012, and whether an IRS W-2 form is attached. Attach copies of all 2012 IRS W-2 forms issued to the parent(s) by employer(s). In the chart below, List every employer even if they did not issue an IRS W-2 form. If more space is needed, attach a separate page with the student s name and Social Security Number at the top. Employer s Name 2012 Amount Earned IRS W-2 Attached? Village Kitchen Restaurant (example) $2, Yes Verification of 2012 IRS Income Tax Return Information for Individuals with Unusual Circumstances 3. Income Tax Return Information for Individuals Granted a Filing Extension If you are required to file a 2012 IRS income tax return, and have been granted a filing extension by the IRS, provide the following documents: A copy of the 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 2012; AND A copy of IRS Form W 2 for each source of employment income received for tax year 2012 and, if self-employed, a signed statement certifying the amount of your AGI and the U.S. income tax paid for tax year Income Tax Return Information for Individuals Who Filed an Amended IRS Income Tax Return If you filed an amended IRS income tax return for tax year 2012, provide BOTH of the following: A signed copy of the original 2012 IRS income tax return that was filed with the IRS or a 2012 IRS Tax Return Transcript (signature not required) for the 2012 tax year; AND A signed copy of the 2012 IRS Form 1040X, Amended U.S. Individual Income Tax Return, that was filed with the IRS.

6 5. Income Tax Return Information for Individuals Who Were Victims of IRS Identity Theft A victim of IRS identity theft who has been unable to obtain a 2012 IRS Tax Return Transcript or use the IRS DRT must provide a signed copy of the 2012 paper IRS income tax return that was filed with the IRS and a signed copy of IRS Form Identity Theft Affidavit if one was submitted to the IRS. If you did not keep a copy of Form or the IRS did not require you to submit one, you may provide one of the following: A statement signed and dated by you indicating that you were a victim of IRS identity theft and that the IRS is investigating the matter. The statement must also indicate that you submitted a Form to the IRS, but did not keep a copy of it or that you were not required to file the form; OR A copy of a police report if it was filed related to the IRS identify theft. 6. Income Tax Return Information for Individuals Who Filed Non-IRS Income Tax Returns If you filed or will file a 2012 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, provide a signed copy of that 2012 income tax return(s). G. Parent s Other Information to Be Verified 1. Complete this section if someone in the student s parent s household (listed in Section B) received benefits from the Supplemental Nutrition Assistance Program or SNAP (formerly known as food stamps) any time during the 2011 or 2012 calendar years. One of the persons listed in Section B of this worksheet received SNAP benefits in 2011 or Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we may require documentation from the agency that issued the SNAP benefits in 2011 or Complete this section if one of the student s parents paid child support in One (or both) of the student s parents listed in Section B of this worksheet paid child support in The parent has indicated below the name of the person who paid the child support, the name of the person to whom the child support was paid, the names of the children for whom child support was paid, and the total annual amount of child support that was paid in 2012 for each child. If asked by the school, I will provide documentation of the payment of child support. If you need more space, attach a separate page that includes the student s name and Social Security Number at the top. Name of Person Who Paid Name of Person to Whom Child Name of Child for Whom Amount of Child Child Support Support was Paid Support Was Paid Support Paid in 2012 Marty Jones(example) Chris Smith Terry Jones $6, H. Parent s (regardless of tax filing status) must list any untaxed income received in BE SURE TO ENTER ZEROS IF NO FUNDS WERE RECEIVED. Parent s 2012 Additional Financial Information (Enter the combined amounts for you and your spouse). e. Taxable earning from need-based employment programs, such as Federal Work-Study, and need-based $ employment portions of fellowships and assistantships.

7 f. Student grant and scholarship aid reported to the IRS in your adjusted gross income. Includes AmeriCorps $ benefits (awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowship and assistantships. g. Combat pay or special combat pay. Only enter the amount that was taxable and included in your adjusted $ gross income. Do not enter untaxed combat pay reported on the W-2 (Box 12, Code Q). h. Earnings from work under a cooperative education program offered by a college. $ I. Parent s Untaxed 2012 Income a. Child support received for any of your children. Do not include foster care or adoption payments. $. b. Housing, food and other living allowances paid to members of the military, clergy and others (including $ cash payments and cash value of benefits). c. Veterans non-education benefits such as Disability, Death Pension, or Dependency & Indemnity $ Compensation (DIC) and/or VA Educational Work-Study allowances. d. Other untaxed income not reported, such as worker s compensation, disability, Homebuyer tax credits, etc. $ Don t include student aid, earned income credit, additional child tax credit, welfare payments, food stamps, untaxed Social Security benefits, Supplemental Security income, Workforce Investment Act educational benefits, combat pay, benefits from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion or credit for federal tax on special fuels. e. Money received or bills paid on your behalf (e.g., friend or family member provided housing or other $ support for living expenses), not reported elsewhere on this form. Please describe and explain calculations in this space: J. Dependent Student s High School Completion Status to Be Verified Provide ONE of the following documents that indicate your high school completion status when you will begin college in : a. A copy of your high school diploma b. A copy of your final official high school transcript that shows the date when the diploma was awarded. c. A copy of your General Educational Development (GED) certificate or GED transcript. d. An academic transcript that indicates you successfully completed at least a two-year program that is acceptable for full credit toward a bachelor s degree. e. If State law does not require a homeschooled student to obtain a secondary school completion credential for homeschool (other than a high school diploma or its recognized equivalent), a transcript or the equivalent, signed by your parent or guardian, that lists the secondary school courses you completed and documents the successful completion of a secondary school education in a homeschool setting. K. Dependent Student s Identity / Statement of Educational Purpose Student appearing in person must submit BOTH of the following: Upon appearance, I will provide an original valid government issued photo identification, including but not limited to a driver s license, non-driver s license, military ID, or passport; AND Upon appearance, I will sign a statement certifying the federal financial aid received will only be used for educational purposes to pay the cost of attending Antioch University for the academic year. Student unable to appear in person must submit BOTH of the following: I will submit by mail, or have attached a copy of a valid government issued photo identification, including but not limited to a driver s license, non-driver s license, military ID, or passport: AND I will submit by mail, (do not fax or ) or have attached the original notarized statement certifying the federal financial aid received will only be used for educational purposes to pay the cost of attending Antioch University for the academic year.

8 L. Certification and Signature Each person signing this worksheet certifies that all of the information reported on it is complete and correct. The student and one parent must sign and date. WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Student s Signature Date Parent s Signature Date Submit completed form to AUM, Financial Aid Office, 900 Dayton Street, Yellow Springs, OH or Scan and to dtomas@antioch.edu or FAX to (937)