Independent

2011-2012 Verification Form for Federal Student Aid Programs

Office of Student Financial Aid901S.National AveSpringfield,MO 65897417-836-5262Fax 417-836-8392

Your application was selected for review in a process called verification. If there are discrepancies between the data on your FAFSA and the verification documents you submit to our office, we will make corrections and send them for reprocessing by the federal processor. A. STUDENT INFORMATION:
______________________________________________________________________________________________________

Last Name

First Name

Bear Pass #

______________________________________________________________________________________________________

Street Address

Date of Birth

______________________________________________________________________________________________________

City

State

Zip Code

Local Phone Number (include area code)

B. FAMILY INFORMATION: List the people in your household, including: yourself and your spouse (if you have one), and your children, if you will provide more than half of their support from July 1, 2011 through June 30, 2012, even if they do not live with you, and; other people 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, 2011 through June 30, 2012. Write the names of all household members in the space(s) below. If you need more space, attach a separate page. * Write the name of the college for any household member who will be attending at least half-time between July 1, 2011and June 30, 2012, and will be enrolled in a degree, diploma, or certificate program. Full Name Age Relationship *College

Self

Missouri State University

PLEASE COMPLETE THE REVERSE SIDE

C.TAX FORMS and INCOME INFORMATION: SECTION 1.

If you did not keep a copy of your U.S. tax return or W-2, call the IRS at 1(800) 829-1040 and request a transcript of your tax forms. Student: (Check one box only) Spouse: (check one box only) Check and attach signed tax return. Check and attach signed tax return. Check if you will not file and are not Check if you will not file and are not required to file a 2010 U.S. Income Tax required to file a 2010 U.S. Income Tax Return. Complete Section 2. Return. Complete Section 2.

SECTION 2.
List all employers and any income received in 2010 for all family members who indicated in SECTION 1 that they did not file and are not required to file a 2010 Federal income tax return. If you have no income to report enter NONE under Source of Income. 2010 Source of Income Is income listed for student or spouse? (List 2010 Income Amount One) $ $ $ $

D. UNTAXED INCOME AND INCOME EXCLUSIONS FOR 2010

List any untaxed income that was received and income exclusions for 2010. Enter zeros if no funds were paid or received. Information requested below is from the Free Application for Federal Student Aid (FAFSA). STUDENT CALENDAR YEAR 2010 SPOUSE

$ $ $ $

$ $ $ $ $

Child support paid because of divorce or separation or as a result of a legal requirement. Dont include support for children in your household. Taxable earnings from need-based work programs such as Federal Work-Study and need-based employment portions of fellowships and assistantships. 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 in Box 12, Code Q Any other untaxed income or benefits not reported, such as workers compensation, disability, etc. Dont include student aid, earned income credit, welfare payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act educational benefit, benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusions or credit for federal tax on special fuels. Money received, or paid on your behalf (e.g. bills), not reported elsewhere on the FAFSA. Payments to tax-deferred pensions and savings plans (paid directly or withheld from earnings), including, but not limited to, amounts reported on the W-2 Form in Boxes 12a through 12d, codes D, E, F, G, H, and S. Child support received for all children. Dont include foster care or adoption payments. Housing, food, and other living allowances paid to members of the military, clergy and others (including cash payments and cash value of benefits). Military basic allowance for subsistence, BAS in box 12 or 14 of W-2 or on Military Leave and Earnings statement. Veterans non-education benefits, such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.

$ $ $ $

$ $ $ $ $

E. SIGN THIS FORM:

By signing this form, I (we) certify that all the information reported on this form is complete and correct. WARNING: If you purposefully give false or misleading information on this form, you may be fined, sentenced to jail, or both. X_________________________________________________ Student Signature Date _________________________________

X_________________________________________________ Date__________________________________ Spouse Signature (Optional) NOTE: This form will be returned to you if information is not fully and accurately completed

Verification Checklist
Steps to completing your Verification Successfully.
Taxes What we need: o Signed copies of the 2010 federal tax returns requested o Include copies of all federal return Schedules filed( such as A,B,C,D,E,F,L) o Include copies of all 2010 W2s and 1099s o Include student name and Bear Pass ID on each document submitted. Verification Form Did you remember to: o Sign the Verification Form o Do not leave any blanks on the Verification Form (Enter zeros or N/A where applicable) o Complete the family grid? (Part B of the Verification Form) o If you/your parents did not file 2010 federal tax return and were not required to file, make sure you complete Part C Section 2 on the Verification Form. o Failure to provide all documentation and information requested by our office will delay the processing of your award. Questions? Contact us!

Office of Student Financial Aid Carrington Hall, Room 101 901 S. National Ave Springfield, Mo 65897 417-836-5262 or 1-800-283-4243 Fax 417-836-8392 financialaid@missouristate.edu