Financial Aid and Scholarships Office 2016-17

Financial Aid and Scholarships Office 2016-17 Verification Form Dependent Name ID Number (required) Your financial aid application for the 2016-17 academic year has been selected for a process called Verification. Verification is a process required by the Department of Education or the California Aid Commission (CSAC) that is intended to improve the accuracy of the information submitted on the Free Application for Federal Aid (FAFSA) or California Dream Act Application. Please complete this form and provide the requested documentation as soon as possible. Deadlines: Please return this form, along with the requested documentation, within three weeks of the date of your email notification to allow time for processing. We recognize that some families may not yet have filed their 2015 tax return. Conditional offers of financial aid, which are estimates based on the information originally reported on your financial aid application, will be available until these forms are received and processed. Please note that U.C. Berkeley s verification review includes a review for institutional funding that is based on different criteria than the review for federal or state funding. This means that institutional grant offers can change significantly once the verification review is completed. Corrections to income reported on the financial aid application may also result in a change to federal or state funding. Release of Information: Due to the federal Family Educational Rights and Privacy Act (FERPA), the Financial Aid and Scholarships Office is not authorized to share information with your parent(s). If you wish to authorize the release of information to a parent or other third party, you may grant them access in the Delegate Access section of your Cal Central profile. To expedite the processing of this form, you may upload it via Cal Central or fax it to: 855-895-3690. If you do not have access to a fax, you may send it to our mailing address: UC Berkeley Financial Aid and Scholarships Office, 2 nd Floor Sproul Hall #1960, Berkeley, CA 94720-1960 In-person drop-off: UC Berkeley Cal Central Office, 120 Sproul Hall SECTION A PARENT(s)/STEPPARENT IN THE HOUSEHOLD: Enter the information for the parent(s) in the household. Email addresses and telephone numbers will be used to contact you if more information is needed. If your biological parents live together but are not married, provide information for both parents. Name of Parent(s)/Stepparent in Household Mo/Day/Year to Email Address (Please print clearly) 1. / / 2. / / Street Address: Daytime Phone: home work Which parent should we contact? Parent 1 Parent 2 City, State, Zip: Evening Phone: home work Which parent should we contact? Parent 1 Parent 2 Page 1 of 6 PLEASE USE BLACK INK 04/27/16 vl

Name: ID#: SECTION B FAMILY MEMBERS ATTENDING COLLEGE AT LEAST HALF TIME List the people in your parent(s) household 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, 2016 and June 30, 2017. If you need more lines, use the explanation section or attach additional pages. If a family member listed is not claimed on your parent(s) tax return, write an explanation below. Include: Yourself, even if you don t live with your parent(s). Your parent(s) other children if (a) your parent(s) will be providing more than half of their support from July 1, 2016 through June 30, 2017, or (b) the children could answer No to every question in Step Three of the FAFSA or Section Two of the California Dream Act Application; and Other people if they now live with your parent(s), your parent(s) provide more than half of their support and will continue to do so from July 1, 2016 through June 30, 2017. Do not list your parent(s) here; list them in Section A. Name of Child Attending College Mo/ Day/Year to Name of College 2016-17 College Grade Level Expected Graduation Month/year 1. / / Self UC Berkeley / 2. / / / 3. / / / 4. / / / Section B Explanation: SECTION C OTHER PEOPLE IN HOUSEHOLD NOT ATTENDING COLLEGE List the people in your parent(s) household who are NOT attending college. Do not report anyone who has already been reported in Section A or B. If you need more lines, use the explanation section or attach additional pages. If a family member listed is not claimed on your parent(s) tax return, write an explanation below. Include: Your parent(s) other children if a) your parent(s) will be providing more than half of their support from July 1, 2016 through June 30, 2017, or b) the children could answer No to every question in Step Three of the FAFSA or Section Two of the California Dream Act Application; and Other people if they now live with your parent(s), your parent(s) provide more than half of their support and will continue to do so from July 1, 2016 through June 30, 2017. Name of Family Member Mo/Day/Year to Name of Family Member Mo/Day/Year to 1. / / 4. / / 2. / / 5. / / 3. / / 6. / / Section C Explanation: Page 2 of 6

Name: ID#: SECTION D BENEFITS In 2014 or 2015, did anyone in your household receive any of the following benefits? Check all that apply. Please provide supporting documentation of benefits received. Answers marked Yes with no documentation will be changed to No. 1. Supplemental Security Income (SSI) Yes No 2. Cal Fresh/SNAP/Food Stamps 3. Free or Reduced Price School Lunch 4. Cal Works/TANF 5. Special Supplemental Nutrition Program for Women, Infants and Children (WIC) 6. As of today, are you (or your spouse) a dislocated worker? In general, a person may be considered a dislocated worker if he or she: a) is receiving unemployment benefits due to being laid off (if a person quits work, generally he or she is not considered a dislocated worker, even if the person is receiving benefits) b) has been laid off or received a lay-off notice c) was self-employed but is now unemployed due to economic conditions d) a displaced homemaker who previously provided unpaid services to the family (e.g., a stay-at-home mom/dad) is no longer supported by the spouse, is unemployed or underemployed and is having trouble finding a job or upgrading employment If yes, please provide an explanation as to why you or your spouse meet this criteria. If no explanation is provided, we will change the answer to No. Yes No SECTION E UNTAXED INCOME Please report income received in 2015 from the sources listed below. If you do not have an amount to report, enter zero next to the dollar sign. Child Support received for any of your children. Don t include foster care or adoption payments. Housing, food, or other living allowances paid to members of the military, clergy, and others. Don t include the value of on-base military housing or the value of a basic military allowance for housing. Veterans non-education benefits, such as Disability, Death pension, or Dependency & Indemnity Compensation. Other untaxed income not reported elsewhere, such as workers compensation, disability benefits, etc. Page 3 of 6

Name: ID#: SECTION F ADDITIONAL PARENT(S) FINANCIAL INFORMATION Do not leave any item blank; enter 0 if there is no value to report. 1. Complete this section if one (or both) of the parent(s) listed in Section A paid child support in 2015 for family members not listed in Sections B and C. Attach documentation (e.g., copies of the most recent court order(s), cancelled checks, or a letter signed by the parent to whom the child support was paid). 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 2015 2. Parents Attending College: Enter the amount of your parent s 2015 taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships 3. Parents Attending College: Enter the amount of your parent s taxable 2015 grants, scholarships, fellowship or AmeriCorps award that was reported on the 2015 tax return as part of Adjusted Gross Income. 4. Combat pay or special combat pay: Enter only the amount that was taxable and included in your parent s Adjusted Gross Income. Do not enter untaxed combat pay reported on the W-2 (Box 12, Code Q). Annual Amount 5. Earnings from work under a cooperative education program offered by a college. SECTION G PARENT(S) & STUDENT ASSET INFORMATION Report all asset values as of the date you filed your 2016-17 FAFSA or California Dream Act Application. Only list the percentage you own of the asset value and debt below. Attach additional pages if necessary. Do not leave any item blank; enter 0 if there is no value to report. CASH, SAVINGS AND CHECKING-foreign and domestic, as of the date you filed your financial aid application Parent(s) Enter the total of your cash, savings and checking accounts. INVESTMENTS- foreign or domestic, as of the date you filed the financial aid application Investments include trust funds, money market funds, mutual funds, certificates of deposit (CD), stocks, stock options, bonds other securities, Coverdell savings accounts, 529 college savings plans, commodities, Uniform Transfers to Minors Act (UTMA)/ Uniform Gifts to Minors Act (UGMA) Custodial Accounts, partnerships/s corporations. Do not include the value of life insurance and retirement plans (401k) plans, pension funds, annuities, non-education IRAs, Keogh plans. Attach additional pages if necessary. Parent(s) Total Value of Investment Assets: BUSINESS/FARM foreign or domestic as of the date you filed the financial aid application Business or farm value includes the market value of land, buildings, machinery, equipment, inventory, etc. Business debt means only the debts for which the business was used as collateral. Do not include the value of family owned and controlled small businesses if your family has more than 50% ownership and it has fewer than 100 full time employees. Do not include farm value if you reside on the property and operate the farm. Attach additional pages if necessary. Parent(s) Business/farm name: Market value: Debt owed: Page 4 of 6

Name: ID#: SECTION G PARENT(S) ASSET INFORMATION-REAL ESTATE REAL ESTATE- foreign or domestic, as of the date you filed the financial aid application Report real estate, other than your primary residence, that you own such as rental property, land, and second or vacation homes. The value is the market value as of the date you filed the financial aid application. Mortgage balance is how much is owed on the property. Include the value of multi-family dwellings that you own (exclude the portion of a dwelling that is your principal residence). List all properties from IRS Form 1040, Schedule E, other properties not reported on IRS Form, and foreign properties not included on a U.S. tax return. Attach additional pages if necessary. Parent(s) SECTION H PARENT(S) TAX FILING STATUS Complete the section below that applies to your parent(s) 2015 federal tax filing status TAX RETURN FILERS ONLY: Complete this section only if the parent(s) listed in Section A filed a 2015 US Federal Income Tax Return. Check all that apply. My parent(s) filed a 2015 U.S. Federal Income Tax Return. Attach a copy of your parent(s) 2015 U.S. Federal Income Tax Return together with all schedules, W-2s, 1099s and other attachments. Do NOT send state tax forms. Your parent must SIGN the tax forms even if they were prepared by someone else, or if the returns were filed electronically. If your parents are married, but did not file jointly, attach both parents signed 2015 tax documents. All documents should be copied onto 8 ½ x 11 paper before submitting. Forms submitted without tax forms will be considered incomplete and will not be processed. My parent(s) filed a non IRS income tax return. An individual who filed or will file a 2015 income tax return in Puerto Rico, another U.S. Territory (e.g. Guam, American Samoa, the U.S. Virgin Islands, the Northern Marianas Islands), or in a foreign country must provide: A signed copy of that 2015 income tax return(s); or 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 2015. Supplemental Foreign Income Information form. This form can be obtained in Cal Central under the Tasks section of My Finances. Page 5 of 6

Name: ID#: NONFILERS ONLY: Complete this section only if the parent(s) listed in Section A did NOT file a 2015 US Federal Income Tax Return and are not required to file. My parent(s) did not file a 2015 U.S Federal Income Tax Return and are not required to file. My parent(s) were not employed and had no income from work in 2015. Report parent income and resources in Sections E, F, and G of this form. My parent(s) were employed in 2015. List below the names of all employers and the amount earned from each employer. Attach copies of all 2015 IRS W-2 forms issued to the parent(s) by the employer(s). List all employers even if they did not issue a W-2 form. Employer Name Contract Earnings; list type (day labor, housekeeping, child care or home care assistant) 2015 Amount Earned 2015 Amount Received Was an IRS W-2 Issued? Any tax document issued? SECTION I - CERTIFICATION The student and one parent must sign and date this form with an original signature (we are not accepting electronic signatures at this time). Each person signing this form certifies that all of the information reported is complete and accurate, and acknowledges that additional documentation may be required. Warning: Purposely providing false or misleading information on this form may result in a fine, jail sentence or both. Signature Parent Signature Date Date To expedite the processing of this form, you may upload it through Cal Central or fax it to: 855-895-3690. If you do not have access to a fax, you may send it to our mailing address: UC Berkeley Financial Aid and Scholarships Office, 2 nd Floor Sproul Hall #1960, Berkeley, CA 94720-1960 In-person drop-off: UC Berkeley Cal Central Office, 120 Sproul Hall To avoid delays, use the checklist below before faxing or mailing your documents. If your form is not completed properly, or documentation is missing, we will not be able to award you any financial aid. Please submit this form, along with the requested documentation, to the Financial Aid and Scholarships Office within three weeks of the date of your email notification to allow time for processing. Did you complete the Verification form in black ink and answer all questions? Blanks will cause your form to be considered incomplete and it will not be processed. A zero should be entered if there is no value to report. Did you SIGN the certification in Section I of this form? Did you photocopy all documentation onto 8 ½ x 11 paper? Did you attach all documentation as instructed on this form? Did you enter your name and student ID number on each page of documentation? Did you keep a copy of everything for your records? Page 6 of 6