*CHSUPC* 1516 *TRACKING REQUIREMENT*
2015 - 2016 CHILD SUPPORT PAID VERIFICATION WORKSHEET
Student Name
Date:
Address
ID#: W
City, State, Zip
Email:
On your Free Application for Federal Student Aid (FAFSA) or your Verification Worksheet, you indicated that you, your
spouse (if married) or your parent(s) (if dependent), paid child support during the year 2014. As part of the verification process,
you must confirm the amount of child support paid, by whom the child support was paid, and to whom it was paid.
SECTION A: Please Check the Box that Applies:
 I (or my spouse if married) paid child support during the year 2014.
 My parent(s) paid child support during the year 2014. (Dependent Students Only)
 Neither I nor my parent(s) paid child support during the year 2014.
If more space is needed, provide a separate page that includes the student’s name and ID number at the top.
SECTION B: If child support was paid during the year 2014 please complete the section below.
Name of person who paid child support
(relationship to student)
Name of person to whom child
support was paid
Name of child for whom support
was paid
Amount of child
support paid in 2014
Note: If we have reason to believe that the information regarding child support paid is not accurate, we may require additional
documentation, such as:
 A copy of the separation agreement or divorce decree that shows the amount of child support to be provided;
 A statement from the individual receiving the child support certifying the amount of child support received; or
 Copies of the child support payment checks or money order receipts.
By signing this worksheet, we certify that all the information reported to qualify for student aid is complete and correct. (At
least one parent must sign if student is dependent. Spouse must sign if responsible for payment of child support.)
Warning: If you purposely give false or misleading information on this application or other financial aid documentation, you may be fined up to
$20,000, sentenced to jail, or both. You will be required to repay any and all aid that you receive as a result of false information provided, and will be
referred for violation of student code of conduct for possible disciplinary action.
Student Signature / Date Signed
Parent (1) Signature / Date Signed
Spouse Signature / Date Signed
Parent (2) Signature / Date Signed
Revised 03/17/15