Dependent Verification Worksheet

Stark State College
Office of Financial Aid
D
6200 Frank Ave NW, North Canton, OH 44720
(330) 494-6170 | Fax-(330) 966-6598
www.starkstate.edu | financialaid@starkstate.edu
DEPENDENT VERIFICATION WORKSHEET
2014-2015
STUDENT NAME
SSC STUDENT ID #
PLEASE READ THESE INSTRUCTIONS CAREFULLY
WHY DO I NEED TO COMPLETE THIS FORM?
Your FAFSA was selected by the U.S. Dept. of Education for review in a process called “Verification.” By federal law (34 CFR, Part
668), Verification requires us to compare information from your FAFSA with copies of your, and your parent(s)’ 2013 Federal tax
return transcript, W-2 forms, and/or other financial documents. If there are differences between your FAFSA information and your
financial documents, corrections may need to be made. Your, and your parent(s)’, signature on the FAFSA indicates willingness to
provide documentation if it is requested. Complete this worksheet and provide the required documents promptly. Participation in
the verification process is NOT optional. We cannot process your financial aid until verification has been completed.
VERIFICATION MUST BE COMPLETED TO RECEIVE FUNDS FROM THE FOLLOWING PROGRAMS:
1. Federal Pell Grant
3. Federal Supplemental Educational Opportunity Grant (SEOG)
2. Federal Direct Loan programs
4. Federal Work-Study
(Subsidized, Unsubsidized and PLUS)
WHAT HAPPENS AFTER VERIFICATION IS COMPLETE?
The verification process takes approximately 30 days from the date the Financial Aid office receives all the required information.
During the verification process we may request additional information. You should check your Student Requirements daily by
logging on to www.starkstate.edu/mystarkstate, select the My Stuff tab, locate the Financial Aid Tools channel, and click the Student
Requirements link. When the verification process is complete and your financial aid package is ready to be viewed, you will receive
an email from the Financial Aid office. Any changes made to your FAFSA during the verification process will be sent directly to the
Federal Processor. The Federal Processor will then communicate changes to you by sending an updated Student Aid Report (SAR).
SECTION 1: HOUSEHOLD INFORMATION
In the grid below list the names of all 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, 2014, through June 30,
2015, or if the other children would be required to provide parental information if they were completing a FAFSA for 20142015. Include children who meet either of the 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 their support and will continue
to provide more than half their support through June 30, 2015.
If any other members of your parent(s) household will be enrolled at least half time in a degree or certificate program at an eligible
postsecondary educational institution between July 1, 2014 and June 30, 2015 include the name of the college. If you need
additional space, attach a separate page.
Full Name
Age
Relationship to Student
College Attending
Self
Stark State College
Student:
Page 1 of 4
SSC STUDENT ID # _________________________
DEPENDENT VERIFICATION WORKSHEET Page 2 of 4
SECTION 2: TAX AND EARNINGS INFORMATION
Tax filers that did not or cannot use the FAFSA IRS Data Retrieval Tool must submit a 2013 IRS Tax Return Transcript.
To obtain a 2013 IRS Tax Return Transcript, go to www.IRS.gov and click the “Get Transcript of your Tax Records” link, then choose
“Get Transcript Online” or “Get Transcript by Mail”. Or you can request a 2013 IRS Tax Return Transcript be mailed to you by calling
the IRS at 1-800-908-9946. Make sure to request the “2013 IRS Tax Return Transcript” and not the “2013 IRS Tax Account
Transcript.” We cannot accept a copy of your 1040, 1040A, 1040EZ, IRS tax account transcript, state tax documents, and/or Forms
8453 and 8879. If you or your parent(s) filed, or will file, a 2013 1040X amended tax return, contact the financial aid office for
additional information about required documentation.
Student Information:



Check here if you used the IRS Data Retrieval Tool on the FAFSA on the web.
Check here if you have attached a copy of your IRS tax return transcript.
Check here if you did not, and are not, required to file a 2013 federal tax return. See non-tax filer’s box below.
NON-TAX FILERS
Only non-tax filers must complete this section. If you did not file and are not required to file a 2013 Federal Income Tax return,
list below any employer(s) and any income received in 2013. Non-tax filers may be asked to contact the IRS to obtain a non-filer
statement.
 Check here if you were not employed and had no income earned from working in 2013.
 Check here if you were employed in 2013. List below the names of all employers and amount earned at each employer.
A copy of all W-2 forms or other earning statements must be submitted.
Employer/Source of Income
Amount Earned in 2013
$
$
$
$
Parent(s)* Information:
*all references to parent(s) include step-parent if re-married



Check here if your parent(s) used the IRS Data Retrieval Tool on the FAFSA on the web.
Check here if your parent(s) have attached a copy of their IRS tax return transcript.
Check here if your parent(s) did not, and are not required to, file a 2013 tax return. See non-tax filer’s box below.
NON-TAX FILERS
Only non-tax filers must complete this section. If you did not file and are not required to file a 2013 Federal Income Tax return,
list below any employer(s) and any income received in 2013. Non-tax filers may be asked to contact the IRS to obtain a non-filer
statement.
 Check here if the student’s parent(s) was not employed and had no income earned from working in 2013.
 Check here if the student’s parent(s) was employed in 2013. List below the names of all employers and amount earned at
each employer. A copy of all W-2 forms or other earning statements must be submitted.
Employer/Source of Income
Amount Earned in 2013
$
$
$
$
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SSC STUDENT ID # _________________________
DEPENDENT VERIFICATION WORKSHEET Page 3 of 4
SECTION 3: OTHER INFORMATION REQUIRED TO BE VERIFIED (STUDENT & PARENT)
CHILD SUPPORT PAID 2013
If you, or your parent(s), paid child support in 2013, please complete the grid below. Contact the Child Support Enforcement
Agency to obtain a payment history from January 2013 through December 2013 for each child listed.
 Check here if you and your parent(s) were NOT required to or did NOT pay any child support in 2013.
 Check here if you or your parent(s) did pay child support in 2013. Documentation of payments is required.
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 2013
$
$
$
$
OTHER PROGRAM FUNDS RECEIVED 2012 & 2013
If you, or anyone in your parent’s household, received any benefits or funds from the following programs in 2012 or 2013,
please check the appropriate box. Supporting documentation may be requested by the financial aid office.







Supplemental Nutrition Assistance Program (SNAP, formerly known as food stamps)
Temporary Assistance for Needy Families (TANF)
Nutrition Program for Woman, Infants & Children (WIC)
Free/Reduced Price Lunch
Supplemental Security Income
Dislocated Worker
Check here if no one in the household received benefits from any of the programs listed
SECTION 4: ADDITIONAL FINANCIAL INFORMATION (STUDENT & PARENT)
Use the table below to report annual amounts for the calendar year 2013 (January 1, 2013 – December 31, 2013). If an item does
not apply, enter -0-. DO NOT LEAVE BLANK. Documentation must be provided for all amounts reported.
2013 ADDITIONAL FINANCIAL INFORMATION
a. Taxable earnings from need-based employment programs, such as Federal Work-Study and
need based employment portions of fellowships and assistantships.
Student
Parent(s)
$
$
$
$
$
$
$
$
Submit all 2013 W-2 forms for documentation.
b. Grant and scholarship aid reported to the IRS in the adjusted gross income. Includes
Americorps benefits (awards, living allowances and interest accrual payments), as well as grant
and scholarship portions of fellowships and assistantships.
Submit 2013 IRS 1040 or all W-2 forms for documentation.
c. Combat pay or special combat pay. Only enter the amount that was taxable and included in the
adjusted gross income. Do not enter untaxed combat pay.
Submit all 2013 W-2 forms for documentation.
d. Earnings from work under a cooperative education program offered by a college.
Submit all 2013 W-2 forms for documentation.
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SSC STUDENT ID # _________________________
DEPENDENT VERIFICATION WORKSHEET Page 4 of 4
SECTION 5: UNTAXED INCOME INFORMATION (STUDENT & PARENT)
Use the table below to report annual amounts for the calendar year 2013 (January 1, 2013 – December 31, 2013). If an item does
not apply, enter -0-. DO NOT LEAVE BLANK. Documentation must be provided for all amounts reported.
2013 UNTAXED INCOME INFORMATION
Student
a. Payments to tax-deferred pension and retirements savings plans (paid directly or withheld from
earnings), including, but not limited to, amounts reported on the W-2 forms in Boxes 12a
through 12d, codes D, E, F, G, H and S. Do not include amounts reported in code DD.
Parent(s)
$
$
$
$
$
$
$
$
$
$
$
XXXXXXXXXX
Submit all 2013 W-2 forms for documentation.
b. Child support received for any children. Do not include foster care or adoption payments.
Submit documentation from the Child Support Enforcement Agency showing all payments
received from January 2013 through December 2013.
c. Housing, food and other living allowances paid to members of the military, clergy and others
(including cash payments and cash value of benefits). Do not include the value of on-base
military housing or the value of a basic military allowance for housing.
Submit 2013 W-2, 1099, or other available documentation.
d. Veterans noneducation benefits, such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC) and/or VA Educational Work-Study allowances.
Submit 2013 W-2, 1099, or other available documentation.
e. Other untaxed income not reported in previous items, such as workers’ compensation,
disability, etc. Also include the untaxed portions of health savings accounts from IRS Form 1040
– line 25. Do not include extended foster care benefits, student aid, earned income credit,
additional child tax credit, welfare payments, untaxed Social Security benefits, Supplemental
Security Income, Workforce Investment Act educational benefits, on-base military housing or a
military housing allowance, combat pay, benefits from flexible spending arrangements (e.g.,
cafeteria plans), foreign income exclusion or credit for federal tax on special fuels.
Submit 2013 W-2, 1099, or other available documentation.
f. Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form.
Report the total amount of cash support you received in 2013. Cash support includes money,
gifts, loans, housing, food, clothing, car payments or expenses, medical and dental care, college
costs, and money paid to someone else on your behalf. Also include distribution amounts from
a 529 plan to you (the student beneficiary) that is owned by someone other than you or your
parents. Dependent students do not count your parents’ support except for money from a noncustodial parent whose financial information is not reported on this form and that is not part of
a legal child support agreement.
CERTIFICATION & SIGNATURES
By signing this worksheet, I certify that all the information reported on this worksheet is complete and correct. WARNING: If false
information is purposely given on this form, a $20,000 fine, a prison sentence, or both could be imposed.
Student Signature
Date
Parent Signature
Date
REQUIRED
Priority Deadlines for Financial Aid
Summer Session
March 1 – FAFSA Filing
April 1 – Required Documentation
May 1 – Loan Request
Fall Session
May 1 – FAFSA Filing
June 1 – Required Documentation
July 1 – Loan Request
Spring Session
October 1
– FAFSA Filing
November 1 – Required Documentation
December 1 – Loan Request
Applications received after these dates will still be considered for aid, but you may not have funds available until after the start of the semester. Be
prepared to use your own funds to pay a portion of your tuition and all of your books before the semester’s payment deadline.
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