Verification of Additional Household Resources for Dependent

Page 1 of 2
DEP
Financial Aid Services 243 Whitmore Administration Building
181 Presidents Drive, Amherst, MA 01003
Phone: 413-545-0801
Web: umass.edu/umfa
Fax: 413-545-1700
Email: finaid@finaid.umass.edu
2015-2016 Verification of Additional Household Resources
PART I: STUDENT INFORMATION
Name:_______________________________________________________________________________________ SPIRE ID:____________________________
Last
First
Middle
Home Address:______________________________________________________________________________________________________________________
# Street
City
Date of Birth: _________/_______/_____________
State
Phone Number: (
Zip
) _________ - _______________
PART II: HOUSEHOLD RESOURCES INFORMATION
Please report below any amount received in 2014 by you and your parent(s). Report total amount received for the entire year.
Do not include student financial aid received. You must check yes or no for each question in order for the form be considered
complete.
Did you or your parent(s)...
...Receive money or have bills paid by someone not in the household?
Parent(s)
•Yes Amount $________
Student
• No
•Yes Amount $________
• No
...Receive income or benefits from the government/state in any of the following forms?
● Social Security Benefits
•Yes Amount $_______
• No
•Yes Amount $________
• No
● Worker’s Compensation
•Yes Amount $________
• No
•Yes Amount $________
• No
● TAFDC or EAEDC
•Yes Amount $________
• No
•Yes Amount $________
• No
● Fuel, Heat, or Energy Assistance
•Yes Amount $________
• No
•Yes Amount $________
• No
● SNAP or WIC
•Yes Amount $________
• No
•Yes Amount $________
• No
● Section 8, MRVP, or AHVP
•Yes Amount $________
• No
•Yes Amount $________
• No
● Railroad Retirement Benefits
•Yes Amount $________
• No
•Yes Amount $________
• No
● Black Lung Benefits
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive cash payment for food, housing, or living expenses as a
member of the military or clergy?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive alimony?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive child support?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive tax-exempt interest income?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive foreign income?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Receive any other forms of income? if yes,
explain: ____________________________________________
•Yes Amount $________
• No
•Yes Amount $________
• No
...Make withdrawals from an IRA, pension, or other retirement account?
•Yes Amount $________
• No
•Yes Amount $________
• No
...Pay into a health saving account?
•Yes Amount $________
• No
•Yes Amount $________
• No
*FDRESE*
Page 2 of 2
DEP
Name:_________________________________________________________________
SPIRE ID:___________________________
If your total annual household income falls below the following 2014 Federal Poverty Guidelines, please provide a detailed
explanation of how the family was supported during the 2014 year in the box below.
# of People
1
2
3
4
5
6
7
8
Each additional
100% FPL
$11,676
$15,732
$19,800
$23,856
$27,912
$31,980
$36,036
$40,092
+$4,068
Explan how the family met all financial obligations in 2014 (rent/mortgage, food, heat, health insurance,taxes,etc.):
PART III: CERTIFICATION
Any financial aid awarded prior to verification is tentative. Financial Aid Services has the right, after reviewing your verification information, to
change or cancel your award. Changes in funding, administrative/technical errors, changes in application information, enrollment status or
reclassification in residency will affect your financial aid award and may result in a revised financial aid award.
By my signature, I certify that all information submitted with and written on this application is complete, accurate, and corrections may be
made based on data provided, and that if I purposely give false or misleading information on this worksheet, I may be fined, sentenced to
prison, or both. I also certify that any federal or state financial aid funds I may receive will only be used to pay for educational expenses
related to my attendance at the University of Massachusetts Amherst for 2015-2016.
____________________________________________________________________________ Please be aware Financial Aid Services is obligated
Student Signature
Date
Parent Signature
Date
to report financial aid applicants that purposely
misreported information or altered documentation
to obtain federal funds to the Office of Inpector
____________________________________________________________________________ General for investigation and prosecution.
Document must be signed with a real signature. Digital signatures are not accepted.
Fax completed, signed form to: 413-545-1700
or email completed, signed form to: fadocs@finaid.umass.edu
(Attachments must be a standard image file, or in one of the following file formats: .doc, .docx, .pdf)
*FDRESE*