2015-2016 CUSTOM
VERIFICATION WORKSHEET
Office of Financial Aid Services
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What is Verification?
Your application was selected by the U.S. Department of Education for review in a process called “Verification”. The Financial Aid
Office must compare information from your FAFSA with information you provide on this worksheet and other documents. If there are
differences between your application information and the documents you submit, your application may need to be reprocessed. The
Financial Aid Office will not make any federal financial aid payments available to you or process a student loan request until all
verification requirements have been met and the necessary corrections have been made.
A. STUDENT AND FAMILY INFORMATION
Last name
First name
M.I.
Address (include apt. #)
City
Social security number
CUNYfirst ID
State
ZIP
Date of birth (mm/dd/yyyy)
(
E-mail address
)
Home#
/(
)
Cell#
Check your appropriate status:
INDE
INDPENDENT STUDENTS: If you answer “Yes” to any of the questions (#46 - #58) in Step Three (FAFSA).
DEPENDENT STUDENTS: If you answer all “No” to any of the questions (#46 - #58) in Step Three (FAFSA).
B. STATEMENT OF EDUCATIONAL PURPOSE
For the 2015-2016 award years, selected applicants will be required to verify their identity, submit a Statement of Educational Purpose
and proof of your high school graduation. To verify your identity, you must present valid government-issued photo identification such as
a state driver’s license, non-driver’s license, military identification or passport to the Financial Aid Office L-409.
I certify that I _______________________________________________am the individual signing this Statement of Educational
(Print Student’s Name)
Purpose and that the federal student financial assistance I may receive will only be used for educational purposes and to pay the cost
of attending Queensborough Community College for 2015-2016.
Student’s Signature
Date
(Students not appearing in person must have this statement of Educational Purpose notarized and mail
the original copy to the Financial Aid Office. A faxed copy cannot be accepted.)
** Notary’s Certificate of Acknowledgement (for mailed copy ONLY) **
STATE OF ________________________
COUNTY OF_______________________
On this___________ day of___________, personally appeared before me the said _______________________________, to
me known to be the individual described in and who executed the foregoing document, and he (she) duly acknowledged to
me that he (she) executed the same, and the statements contained therein are true.
___________________________________________________
Notary Public or Commissioner of Deeds (if you have an official seal, please affix it)
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C. SNAP VERIFICATION GROUP
Did you or a member of your parent(s) household receive Food Stamps (SNAP) in 2013 and/or 2014?
(Please note that SNAP is the new name for Food Stamps, but it may have a different name in your state)
Yes ______ or No ______
If yes, please complete the following information for the person in your household receiving Food Stamp (SNAP) benefits.
If you are the one receiving benefits, please indicate “self” in “Relationship to Student.”
__________________________________________ _______________________________
Name of Recipient
Relationship to Student
________________________________________________________
Street Address
(
)___________-______________________
Phone # (include area code)
____________________________________________________________________________________________________
City
State
Zip
D. CHILD SUPPORT PAID VERIFICATION GROUP
Did you pay child support in 2014?
If Yes_____, please complete the following: or No ______
(Do not include child support paid for children listed on your FAFSA as part of your household size)
___________________________________________ $____________________
Name of Person who paid the child support
2014 Yearly Total Paid
___________________________________________ _______________________________________________
Name of child support recipient(s)
Recipient’s address
___________________________________________________________________________________________
List name of each child not living in your household for whom support was paid
E. CERTIFICATION
By signing this document, you read and certify that the information reported is complete and correct. If it appears the information in
this document is inaccurate, we may request a statement from the individual receiving the support, copies of child support checks,
and/or a copy of the divorce decree. WARNING: If you purposely give false or misleading information on this worksheet, you
may be fined, be sentenced to jail, or both.
________________________________________________
Student’s Signature
________________________
Date
_________________________________________________
Spouse’s Signature (only required if spouse paid child support)
________________________
Date
_________________________________________________
Parent’s Signature (only required if student is a dependent)
________________________
Date
*********************************FOR OFFICE USE ONLY*********************************
Proof of Identity
Student has shown proof of identity in the form of photo identification such as a driver’s license or passport.
Type of Valid Government Issued ID Collected: ______________________________________________________
College Representative’s Signature
Date