2010-2011 Financial Aid

Verification Worksheet/Independent

A. Student Information

Last Name First Name MI Last 4 digits of SSN IRN

B. Family Information
1. In the table below, list the names of all family members that you (and/or your spouse) will support between July 1, 2010 and June
30, 2011.

Include:

• Yourself
• Your spouse
• Your children, if you will provide more than half of their support from July 1, 2010 through June 30, 2011, even if they do
not live with you.

Include other people as part of your family only if:

• They now live with you, and you provide more than half of their support and will continue to provide more than half of
their support from July 1, 2010 through June 30, 2011.

2. In the table below, next to the names of those listed from step one above, write in the names of the college for any household
member, excluding your parent(s)/step-parent(s), who will be attending/enrolled in a degree or certificate program at a Title IV
eligible college at least half-time between July 1, 2010 and June 30, 2011.

Full Name Age Relationship to Student College and/or University Name

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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 2010-2011 Financial Aid
Verification Worksheet/Independent

C. Tax Forms and Income Information

1. Attach a copy of your (and spouses) signed 2009 federal income tax return to this verification worksheet (required to
process Federal Student Aid). If you are unable to retrieve a copy of your 2009 tax return, you may also submit a copy of
your tax transcript that can be obtained from the IRS.

2. If you or your spouse received untaxed income, indicate the source and the amount below. [See Question 45 of the Free
Application for Federal Student Aid (FAFSA)]

Student’s Sources of Untaxed Income Amount/year Spouse’s Sources of Untaxed Income Amount/year
2009 2009
a. Child Support $ a. Child Support $
b. Workman’s Compensation $ b. Workman’s Compensation $
c. Untaxed Pensions $ c. Untaxed Pensions $
d. $ d. $
e. $ e. $
f. $ f. $

NON TAX FILERS

If y ou or y our spouse did not and were not required t o f ile a 2009 Federal income tax return, complete the following, using t he W -2
form or other earnings statements if available. If you did not file, but were required to do so, you may be ineligible for financial aid.

I (we) did not file and are not required to file a 2009 Federal Income Tax Return.  Student  Spouse

Student’s employer and/or source of Amount/year Spouse’s employer and/or source of Amount/year
income received for 2009 income received for 2009
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $
$ $

D. Student Signature
By signing this worksheet, I certify that all the information reported on this worksheet is complete and correct.

Student Signature Date

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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