2016-2017 Verification Worksheet
LMU Financial Aid Office
6965 Cumberland Gap Parkway
Harrogate, TN 37752
Phone: 423.869.6336
Fax: 423.869.6347
Dependent
V6
Your 2016-2017 Free Application for Federal Student Aid (FAFSA) was
selected for a process called verification. The Federal Regulations say that
before awarding Federal Student Aid, we must ask you to confirm the
information you and your parents reported on your FAFSA. To verify that
you provided correct information, our financial aid administrator will compare
your FAFSA with the information on this worksheet and with any other
required documents. If there are differences, your FAFSA information may
need to be corrected. You and at least one parent must complete and sign this
worksheet, attach any required documents, and submit the form and other
required documents to the financial aid office. We may ask for additional
information. If you have questions about verification, contact the financial aid
office as soon as possible so that your financial aid will not be delayed.
What you should do:
1. If you did not use the IRS Data Retrieval Tool on your
FAFSA, you must submit a 2015 tax return transcript
from the IRS. Per federal regulations, a copy of your
federal tax return is no longer acceptable.
2. Complete all sections of the worksheet and provide
the required signature(s).
3. Talk to your financial aid administrator if you have
questions about completing this worksheet.
4. Deliver, mail, or fax the completed worksheet, tax
return transcript, and any other documents to the
Financial Aid Office as soon as possible in order for
your financial aid to be processed.
A. Student Information
Last name
First name
M.I.
Date of birth
Address (include apt. no.)
City
LMU ID
State
Phone number (include area code)
ZIP Code
B. Family Information
List the people in your parent(s)’ household, including:
• yourself and your parent(s) (including stepparent) even if you don’t live with your parents, and
• your parents’ other children, even if they don’t live with your parent(s), if (a) your parents will provide more than half of their
support from July 1, 2016 through June 30, 2017, or (b) the children would be required to provide parental information when
applying for Federal Student Aid, and
• other people if they now live with your parents, and your parents provide more than half of their support and
will continue to provide more than half of their support from July 1, 2016 through June 30, 2017.
Write the names of all household members in the space(s) below. Also write in the name of the college for any household member,
excluding your parent(s), who will be attending at least half time between July 1, 2016 and June 30, 2017, and will be enrolled in a
degree, diploma, or certificate program. If you need more space, attach a separate page.
Full Name
Age
Relationship
Self
College
Lincoln Memorial University
Student Name: _____________________________
Student ID #: ___________________________
C. Student’s Tax Forms and Income Information
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**NOTE: Tax filers must attach a copy of their IRS Federal 2015 tax return transcript if they did not use the
IRS Data Retrieval Tool on the FAFSA.
To obtain a copy of your IRS Tax Return Transcript,
go to http://www.irs.gov/Individuals/Get-Transcript or call 1-800-908-9946.
1.
Did you file a 2015 Federal Tax Return?
Yes, I filed a 2015 Federal Tax Return and I used the IRS Data Retrieval Tool. (skip to section D)
Yes, I filed a 2015 Federal Tax Return and I am attaching a copy of my tax return transcript. (skip to section D)
No, I did not file and was not required to file a 2015 Federal Tax Return. (If no, please answer question 2.)
2.
TAX RETURN NONFILERS – Complete this section if you will not file and are not required to file a 2015 income tax return
with the IRS. Check the box that applies:
The student was not employed and had no income earned from work in 2015.
The student was employed in 2015. Please complete the table below and attach copies of all W-2s. List every employer,
even if the employer did not issue a W-2 form. (Attach another sheet if additional space is needed.)
Income earned from work: Use the W-2 or other earnings statements (Non-tax filers only)
Employer(s) Name
2015 Amount Earned
W-2 Attached?
$
$
D. Parent(s)’ Tax Forms and Income Information
1.
Did your parent(s) file a 2015 Federal Tax Return?
Yes, the parent(s) filed a 2015 Federal Tax Return and used the IRS Data Retrieval Tool. (skip to section E)
Yes, the parent(s) filed a 2015 Federal Tax Return and is attaching a copy of the tax return transcript. (skip to section E)
No, the parent(s) did not file and was not required to file a 2015 Federal Tax Return. (If no, please answer question 2.)
2.
TAX RETURN NONFILERS – Complete this section if your parent(s) will not file and are not required to file a 2015 income
tax return with the IRS. Check the box that applies:
The parent(s) was not employed and had no income earned from work in 2015.
The parent(s) was employed in 2015. Please complete the table below and attach copies of all W-2s. List every employer,
even if the employer did not issue a W-2 form. (Attach another sheet if additional space is needed.)
Income earned from work: Use the W-2 or other earnings statements (Non-tax filers only)
Employer(s) Name
2015 Amount Earned
W-2 Attached?
$
$
E. Parent’s Other Information to be Verified
1. Did the student’s parent(s) pay child support in 2015?
Name of Person Who Paid
Child Support
Name of Person to Whom
Child Support was Paid
Yes (If yes, complete the chart below)
Name of Child for Whom
Child Support was Paid
Amount of Child Support Paid
in 2015
$
$
2. During 2014 or 2015, did any member of the household receive SNAP (food stamps) benefits?
Yes
No
No
Student Name: _____________________________
Student ID #: ___________________________
F. Other Untaxed Income
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**Please attach ALL 2015 W2 forms if student and parent(s) earned income from work in 2015.**
Answer each question below as it applies to the student and parent(s). If any item does not apply, enter “0.”
2015 Untaxed Income
Parent(s)
Student
Payments to tax-deferred pension and retirement savings
$
List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings
plans (e.g., 401(k) or 403(b) plans), including, but not limited to, amounts reported on W-2 forms in
Boxes 12a through 12d with codes D, E, F, G, H, and S.
Child support received for all children
$
/year
$
/year
$
List the actual amount of any child support received in 2015 for the children in your household.
/year
Do not include foster care payments, adoption payments, or any amount that was court-ordered but not
actually paid.
Housing, food, and other living allowances paid to members of the military, clergy and
others
$
/year
$
/year
Include cash payments and/or the cash value of benefits received.
/year
Do not include the value of on-base military housing or the value of a basic military allowance for
housing.
Veteran’s noneducation benefits
$
List the total amount of veterans non-education benefits received in 2015. Include Disability,
Death Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work
Study allowances.
$
/year
/year
Do not include federal veterans educational benefits such as: Montgomery GI
Bill, Dependents Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill
Other Untaxed Income
$
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include
untaxed income such as workers’ compensation, disability, Black Lung Benefits, untaxed portions of
health savings accounts from IRS Form 1040 Line 25, Railroad Retirement Benefits, etc.
$
/year
/year
Do not include any items reported or excluded in A – D above. In addition, do not include student aid,
Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF),
untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (WIA)
educational benefits, combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans),
foreign income exclusion, or credit for federal tax on special fuels.
Money received, or paid on your behalf (e.g. bills), not reported elsewhere on this form
List any money received or paid on the student’s behalf (e.g., payment of student’s bills) and not reported
elsewhere on this form. Enter the total amount of cash support the student received in 2014. Include
support from a parent whose information was not reported on the student’s 2016–2017 FAFSA, but do
not include support from a parent whose information was reported. For example, if someone is paying
rent, utility bills, etc., for the student or gives cash, gift cards, etc., include the amount of that person's
contributions unless the person is the student’s parent whose information is reported on the student’s
2016–2017 FAFSA. Amounts paid on the student’s behalf also include any distributions to the student
from a 529 plan owned by someone other than the student or the student’s parents, such as grandparents,
aunts, and uncles of the student.
$
/year
G. Sign this Worksheet
By signing this worksheet, I certify that all the information reported on this worksheet is complete and correct. I also understand that if any of
the information reported on this form is inconsistent with what has been reported on the FAFSA, additional documentation may be required.
WARNING:
Student’s Signature
Parent’s Signature
Date
Date
If you purposely give false or misleading
information on this worksheet, you may be
fined, be sentenced to jail, or both.