*DEPVER* 1617
*TRACKING REQUIREMENT*
2016–2017 Verification Worksheet - Dependent Student
Your application was selected for review in a process called “Verification.” Your school must compare information from your application with you and
your parent(s)’ 2015 IRS Tax Return Transcripts, W-2 and/or other 2015 financial documents. Federal regulations say we have the right and
responsibility to require this information before awarding Federal aid. If there are differences between your application and your verification documents,
corrections may need to be submitted to the Department of Education. Please answer carefully and completely.
Incomplete information will not be reviewed, will be returned to you and you will delay the processing of your file
A. Student Information
W#:
________________________________________________________________
Last Name
First Name
M.I.
_______________________
Social Security Number
________________________________________________________________
Address (include apt. #)
______________________________________
Email Address
________________________________________________________________
City
State
Zip Code
______________________________________
Phone Number (including area code)
________________
Date of Birth
 I have read and understand the new limits to the Federal Pell Grant program.
Pell Lifetime Eligibility Used (LEU) Effective July 1, 2012, students are limited to a lifetime maximum Pell Grant of 12 semesters / six years or full time
equivalent (600%) at any community college, vocational school or four year/bachelor program. Once you reach the 600% Pell LEU, you are ineligible for any
additional Pell Grant. Log onto www.nslds.ed.gov using your FAFSA PIN and view your LEU, found on the Financial Aid Review page. For more
information: http://studentaid.ed.gov/PORTALSWebApp/students/english/PellLimit.jsp
What this means for you: You must plan now for your future, especially if you plan to transfer to a four year college for a Bachelors degree. The six year
limit is a LIFETIME limit, regardless of completion of your academic goals or Bachelors degree. This regulation is in effect even if you have had an appeal
approved for failure to meet academic progress, it supersedes any prior offer of aid/award, and the Department of Education allows for no appeal or exception.
B. Family Information
List the people in your parents’ household. You may only include:
 yourself and your parent(s) (including stepparent, unmarried and both parents living together) 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. the children would be required to provide parental information when applying for Federal Student Aid, OR
B. your parents will provide more than half of their support from July 1, 2016 through June 30, 2017, and
 other people if they now live with your parents, and your parents provide more than half their support and will continue to provide more than
half of their support from July 1, 2016 through June 30, 2017. You may not include roommates.
Write the names of only those household members meeting definition above. Then indicate the name of the college for any household member,
excluding your parent(s), who will be attending college at least half time in a degree or certificate program between July 1, 2016 and June 30, 2017. If
you need more space, attach a separate page.
Full Name
Age
Relationship
Self
Name of College (if attending)
Chabot Community College
Revised 02/11/16
C. Student’s Income Information to Be Verified
1. TAX RETURN FILERS
Instructions: Complete this section if the student filed or will file a 2015 income tax return with the IRS. Note: If you were
required to amend taxes, you must provide copies of both the original tax document as well as the amended tax transcript
(1040X) before completing or submitting this document.
The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If the student
and/or parent(s) have not already used the tool, go to FAFSA.gov, log in to the student’s FAFSA record, select “Make
FAFSA Corrections,” and navigate to the Financial Information section of the form. From there, follow the instructions
to determine if the student and/or parent(s) are eligible to use the IRS Data Retrieval Tool to transfer 2015 IRS income
tax information into the student’s FAFSA. It takes up to two weeks for IRS income information to be available for the IRS
Data Retrieval Tool for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers.
Check the correct box:
 The student/spouse used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and transfer 2015 IRS income


information into the student’s FAFSA, (on initial FAFSA or when making a correction), and has NOT changed that
information. The student’s school will use the transferred IRS information to complete the verification process.
The student has not yet used the IRS Data Retrieval Tool, but will use the tool to retrieve and transfer 2015 IRS income
information into the student’s FAFSA once the student has filed a 2015 IRS tax return. See instructions above to use the
IRS Data Retrieval Tool. The student’s school cannot complete the verification process until the IRS information has been
transferred into the FAFSA.
The student is unable or chooses not to use the IRS Data Retrieval Tool, and the student will submit a 2015 IRS tax
return transcript—not a photocopy of the income tax return.
 Check here if the student’s IRS tax return transcript is attached to this worksheet.
To obtain an IRS tax return transcript, go to www.IRS.gov and click on the “Order a Tax Return Transcript” link, or call
1-800-908-9946. Make sure to request the “IRS tax return transcript” (not the “IRS tax account transcript”). Student
and parent(s) will each need a Social Security Number, date of birth, and the address on file with the IRS (normally this
will be the address used when the 2015 IRS tax return was filed). It takes up to two weeks for IRS income information to
be available for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers. If the parents are
married, separate or unmarried and both parents living together) 2015 tax returns were filed, 2015 IRS tax return transcripts
must be submitted for each parent.
2. TAX RETURN NONFILERS Complete this section if the student will not file and is not required to file a 2015 income tax
return with the IRS. See page 7 of 2015 1040 instructions or contact the IRS to determine if you are required to file federal taxes.

NON-TAX FILERS –By checking this box, I certify that I did not and am not required by the IRS to file a 2015 Federal Income
Tax Return. For non-filer status, we may require that you download form 4506-T from mark checkbox #7 and follow mailing
instructions on the form.
 The student was not employed and had no income earned from work in 2015.
 The student was employed in 2015 and has listed below the names of all the student’s employers, the amount earned
from each employer in 2015, and whether an IRS W-2 form is attached. Attach copies of all 2015 IRS W-2 forms
issued to the student by employer(s). List every employer even if they did not issue an IRS W-2 form. If more space is
needed, attach a separate page with the student’s name and Social Security Number at the top.
Employer’s Name
2015 Amount Earned
IRS W-2 Attached?
Suzy’s Auto Body Shop (example)
$2,000.00(example)
Yes(example)
What were your main sources of financial support during the past year? Please check all that apply.
__ Income from work*
__ Legal Settlement*
__ Student Financial Aid
__ Savings*
__ Unemployment*
__ WIC
__ Child Support Received/Alimony* __ Assistance from friends or relatives*
__ Subsidized Housing
__ Food Stamps
__ Other _______________________________________
Revised 02/11/16
D. Parent’s Income Information to Be Verified
Note: If two parents/stepparents were reported in Section B of this worksheet, the instructions and certifications below refer
and apply to both parents/stepparents.
1. TAX RETURN FILERS
Instructions: Complete this section if the student’s parent(s) filed or will file a 2015 income tax return with the IRS. Note: If
the student’s parent(s) were required to amend taxes, you must provide copies of both the original tax document as well as the
amended tax transcript before completing and submitting this document.
The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If the student
and/or parent(s) have not already used the tool, go to FAFSA.gov, log in to the student’s FAFSA record, select “Make
FAFSA Corrections,” and navigate to the Financial Information section of the form. From there, follow the instructions
to determine if the student and/or parent(s) are eligible to use the IRS Data Retrieval Tool to transfer 2015 IRS income
tax information into the student’s FAFSA. It takes up to two weeks for IRS income information to be available for the IRS
Data Retrieval Tool for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers.
Check the box that applies:
 The student’s parent used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2015 IRS income information
into the student’s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA, and has NOT changed
that information. The student’s school will use the transferred IRS information to complete the verification process.
 The student’s parent has not yet used the IRS Data Retrieval Tool, but will use the tool to retrieve and transfer 2015 IRS
income information into the student’s FAFSA once the parent has filed a 2015 IRS tax return. See instructions above to
use the IRS Data Retrieval Tool. The student’s school cannot complete the verification process until the IRS information
has been transferred into the FAFSA.
 The parent is unable or chooses not to use the IRS Data Retrieval Tool, and the parent will submit a 2015 IRS tax return
transcript—not a photocopy of the income tax return.
 Check here if parent’s IRS tax return transcript(s) is attached to this worksheet.
To obtain an IRS tax return transcript, go to www.IRS.gov and click on the “Order a Return or Account Transcript” link,
or call 1-800-908-9946. Make sure to request the “IRS tax return transcript” (not the “IRS tax account transcript”).
Student and parent(s) will each need a Social Security Number, date of birth, and the address on file with the IRS
(normally this will be the address used when the 2015 IRS tax return was filed). It takes up to two weeks for IRS income
information to be available for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers. If
the parents are married, and separate or unmarried and both parents living together) 2015 tax returns were filed, 2015
IRS tax return transcripts must be submitted for each parent.
2. TAX RETURN NONFILERS—Complete this section if the student’s parent(s) will not file and are not required to file a 2015
income tax return with the IRS. See page 7 of 2015 1040 instructions or contact the IRS to determine if you are required to file
federal taxes.

NON-TAX FILERS –By checking this box, we certify that we did not and are not required by the IRS to file a 2015 Federal
Income Tax Return. For non-filer status, we may require that you download form 4506-T from mark checkbox #7 and follow
mailing instructions on the form.
 The parent(s) was not employed and had no income earned from work in 2015.
 The parent(s) was employed in 2015 and has listed below the names of all the parent’s employers, the amount earned
from each employer in 2015, and whether an IRS W-2 form is attached. Attach copies of all 2015 IRS W-2 forms
issued to the parent(s) by employer(s). List every employer even if they did not issue an IRS W-2 form. If more space is
needed, attach a separate page with the student’s name and Social Security Number at the top.
Employer’s Name
Suzy’s Auto Body Shop (example)
2015 Amount Earned
$2,000.00 (example)
IRS W-2 Attached?
Yes (example)
What were your main sources of financial support during the past year? Please check all that apply.
__ Income from work*
__ Legal Settlement*
__ Student Financial Aid
__ Savings*
__ Unemployment*
__ WIC
__ Child Support Received/Alimony* __ Assistance from friends or relatives*
__ Subsidized Housing
__ Food Stamps
__ Other _______________________________________
Revised 02/11/16
Parent’s Other Information to Be Verified
1. Complete this section if someone in the parent’s household (listed in Section B) received benefits from the Supplemental
Nutrition Assistance Program or SNAP (formerly known as food stamps) any time during the 2014 or 2015 calendar years.
 One of the persons listed in Section B of this worksheet received SNAP benefits in 2014 or 2015. If asked by the student’s
school, I will provide documentation of the receipt of SNAP benefits during 2014 and/or 2015.
2. Complete this section if one of the student’s parents paid child support in 2015.
 One (or both) of the student’s parents listed in Section B of this worksheet paid child support in 2015. The parent has
indicated below the name of the person who paid the child support, the name of the person to whom the child support was
paid, the names of the children for whom child support was paid, and the total annual amount of child support that was
paid in 2015 for each child. I have attached documentation of the payment of child support.
Name of Person Who Paid
Child Support
Name of Person to Whom Child
Support was Paid
Name of Child for Whom
Support Was Paid
Marty Jones
Chris Smith (example)
Terry Jones
Amount of Child
Support Paid in
2015
$6,000.00
E. Income Exclusions (Question 44 and 93 on FAFSA)
If no items apply to you (or your parents), enter zeros. Documentation will be required and
Student
Parent
must be attached for us to exclude these dollar amounts from your financial aid calculation.
$
Taxable earnings from federal Work-Study or other need-based work program; only may
include here if included as income on your 2015 taxes. (2015 federal taxes and W2)
$
$
Student grant, scholarship, fellowship, or assistantship aid, including Ameri-Corps
awards, as reported to the IRS in your adjusted gross income. (2014 federal taxes and
school's end of year statement of qualifying amounts/1098)
$
$
Combat pay or special combat pay. Only enter the amount that was taxable and included
in your adjusted gross income on 2015 federal taxes.
$
$
Earnings from work under a cooperative education program offered by a college.
$
F. Certification and Signatures
I certify that 1) I have read this entire form and understand the information it contains, 2) the information I have provided here is
true, complete and accurate to the best of my knowledge, and 3) I have attached documentation if required to do so.
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
_______________________________________________________
Parent / Stepparent Signature (Required)
Date
Do not mail this worksheet to the U.S. Department of Education.
Submit this worksheet with appropriate documentation to the financial aid administrator at your school.
You should make a copy of this worksheet for your records.
Revised 02/11/16