Office Use Only: Ready for Review
Initial: _________ Date:____________
Rechecked File: _______ Date: ______
Office Use Only: Initial: ________ Trans #: ________
Verified: ____/____/____
Change
No Change
Original EFC: ________
New EFC: ________
2016-2017 VERIFICATION WORKSHEET
Independent Student V5
You have been selected by the U.S. Department of Education for a review process called Verification. This review requires you to
submit this completed worksheet, Federal Tax Return Transcripts (if requested), and other documentation to Kutztown University
Financial Aid Services, PO Box 730, Kutztown, PA 19530. Phone: 610-683-4077 or Fax: 610-683-1380. Please make sure all
necessary signatures are included.
FINANCIAL AID CANNOT BE AWARDED UNTIL THE VERIFICATION PROCESS HAS BEEN COMPLETED.
Section A: Dependent Student’s Information
______________________________________________________
___________________________
Student’s Last Name
Kutztown University Student’s ID
Student’s First Name
Student’s M. I.
___________________________________________________________________
Home Street Address (includes apt. #)
_________________________________
Student’s Date of Birth
___________________________________________________________________
City
State
Zip Code
_________________________________
Student’s Email Address
___________________________________________________________________
Student’s Home Phone Number (include area code)
_________________________________
Student’s Cell Phone Number
Section B: Household Information
Current Marital Status of Student:
Single
Married or Remarried
Separated or Divorced
Widowed
Below, list the people in your household. Include:



Yourself , your spouse and your children
Other children, only if you will provide more than half of their support between July 1, 2016 and June 30, 2017
Other people if they now live with you, and only if you provide more than half of their support and will continue to provide
more than half of their support between July 1, 2016 and June30, 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,
who will be attending college at least half-time between July 1, 2016 and June 30, 2017, and will be enrolled in a program that leads
to a college degree or certificate.
Full Name
Age
Relationship
College
Example: __________Mary Smith_____________________
____18____ ___________Sister_______________
____________XYZ University_________
__________________________________________________
___________ _______You, the student________
__________Kutztown University_______
__________________________________________________
___________
_______________________________
____________________________________
__________________________________________________
___________
_______________________________
___________________________________
__________________________________________________
___________
__ ____________________________
___________________________________
___________________________________________ ______
___________
______________________________
___________________________________
If you need more space, attach a separate sheet.
Page 1 of 5
Student Name:_______________________________
IV5
Section C: Tax Forms and Income Information (student and spouse)
ID#:__________________________________
1. TAX RETURN FILERS
Instructions: Complete this section if the student and/or spouse filed or will file a 2015 federal income tax return with the IRS.
 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 spouse has not already used this 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 spouse is 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. If you need
more information about when or how to use the IRS Data Retrieval Tool, contact Financial Aid Services at 610-683-4077,
email financialaid@kutztown.edu, or contact FAFSA at 1-800-433-3243.
Student and/or
Spouse used the IRS Data Retrieval Tool through FAFSA.
**Even though your information has been transferred electronically, please make sure that you enclose all copies of
W2s for 2015 for both student and/or spouse. **
If the student and/or spouse is unable or chooses not to use the IRS Data Retrieval Tool, submit a 2015 IRS tax return
transcript(s) – we cannot accept a photocopy of the income tax return.
 To have a copy of a 2015 tax return transcript mailed, go to https://www.irs.gov/Individuals/Get-Transcript and click on
“Get Transcript by Mail.” Enter the social security number, date of birth, street address and postal code for the person
whose transcript you are requesting. For the type of transcript select “Return Transcript” and for tax year select “2015.”
The tax return transcript should be received in the mail within 5-10 business days from the date of request. It takes up to
two weeks for the IRS income information to be available for electronic IRS tax return filers, and up to eight weeks for
paper tax return filers.
 If you are not able to retrieve the transcript from the website, you will need to call the IRS at 1-800-908-9946. Make
sure that you are requesting the “IRS tax return transcript” and not the “IRS tax account transcript.” You will need your
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 the IRS income information to be available for electronic
IRS tax return filers, and up to eight weeks for paper tax return filers.
Student’s and/or
Spouse’s IRS tax return transcript will be submitted to Financial Aid Services later.
Student and/or
Spouse filed or will file an extension for the 2015 tax year.
Student and/or
Spouse filed or will file an amended 2015 IRS tax return.
OR
OR
Verification cannot be completed until the IRS tax return transcript(s) has been submitted to Financial Aid Services.
2. TAX RETURN NON-FILERS
Complete this section if the student and/or parent will not file and is not required to file a 2015 income tax return with the
IRS.
Check the box or boxes that apply:
A. I/We did not file and are not required to file a 2015 federal income tax return.
Student
V Student’s Spouse V
e
If you or your parent didenot file and are not required
to file, list below you and/or your parent(s) employers, the
r
r whether a W-2 form is attached. Please submit a copy of your W-2
amount earned from each employer in 2015, and
i
forms to Financial Aid Services.
If no income fori 2015, put “0.” Do not leave blank.
f
f
Student’s Employer(s)
i
i
Amount(s)
W-2s Attached
Parent’s employer(s)
Amount(s)
W2s Attached
c
Yesc
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ABC Shipping
$ 980
$ 1,280
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c 2 of 5
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Student Name:_______________________________
Section D: SNAP and Child Support Paid
1.
ID#:__________________________________
One of the persons listed in your household received SNAP (Supplemental Nutrition Assistance Program) benefits in 2014 or
2015.
Yes
2.
IV5
No
You (or if marred, your spouse) paid child support in 2015.
Yes
No
___________________________________________________
Signature of person who paid child support
Date
Name of Person Who Paid
Child Support
Name of Person to Whom Child
Support Was Paid
Name of Child for Whom
Support Was Paid
Age of Child for
Whom Support
Was Paid
Amount of Child Support
Paid in 2015
Ex: Joseph Jones
Jane Doe
Jacob Jones
5
$6,000
$
$
$
Total: $
.00
.00
.00
.00
If you need more space, attach a separate piece of page that includes the student’s name and social security number at the top.
Please enter amount received in 2015 or enter “0” if the answer is “none” for sections E and F. Do not leave any item blank.
Section E: 2015 Additional Financial Information:
Student
$____________ Taxable earnings from need-based employment programs, such as Federal Work-Study.
Spouse
$____________
$____________ Combat pay or special combat pay; only enter the amount that was taxable.
$____________
Section F: 2015 Untaxed Income:
$____________ Child support received for all children. Don’t include foster or adoption payments.
$____________
$____________ Housing, food and other living allowances paid to members of the military, clergy and
others (including cash payments and cash value of benefits). Don’t include the value of
on-base military housing or the value of a basic military allowance for housing.
$____________
$____________ Veterans non education benefit – list benefit: ________________________________
$____________
$____________ Other untaxed income not reported above, such as workers’ compensations, disability, etc.
List source of untaxed income: _____________________________________________
$____________
$____________ Money received or paid on your behalf (e.g., bills), not reported elsewhere on this form.
Section G: High School Completion Status
In order for your financial aid to be disbursed, if you have not already done so, you are required to submit proof to the Kutztown
University Admissions Office that you have met high school graduation requirements. Submit one of the following:
 Official final high school transcript showing date of graduation which must be requested from the high school you
graduated from and arrive in a sealed envelope directly from the high school.
 Proof of successful completion of a GED.
 Homeschooled – if an official high school diploma is not awarded by an agency, homeschooled applicants must submit
the GED diploma and the scores from all five sections of the test. This information must be mailed directly from the
Department of Education issuing the diploma.
Page 3 of 5
IV5
Student Name:_______________________________
ID#:__________________________________
For sections H and J, student must appear either in person or sign in the presence of a Notary.
Only complete whichever option you choose.
Section H: Identity and Statement of Educational Purpose (TO BE SIGNED AT KUTZTOWN UNIVERSITY)
You, the student, must appear in person at Kutztown University’s Financial Aid Office to verify his or her identity by presenting a
valid government-issued photo identification, such as, but not limited to, a driver’s license, other state-issued ID, or passport (A
Kutztown University ID is not acceptable.) Kutztown University will maintain a copy of the student’s government-issued photo ID
notated with the date it was received and the name of the official at the institution authorized to collect the student’s ID.
In addition, you must sign, in the presence of the institution official, the following:
Statement of Educational Purpose
I certify that I _______________________________________am the individual signing this Statement of Educational
(Student Print 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 Kutztown University for 2016-2017.
_______________________________________ _________
_________ _________
Student’s Signature
FAO Initials
Date
Date
Warning: If you purposefully give false or misleading information on
this worksheet, you may be fined, be sentenced to jail, or both.
Section I: Certification and Signatures
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. The student must
sign and date this worksheet. If married, the spouse’s signature is required.
________________________________________________
Student’s Signature
__________________________________________
Date
________________________________________________
Spouse’s Signature
__________________________________________
Date
If the student is unable to appear in person to Kutztown University, continue on to Section H and
complete Section I in the presence of a notary.
Page 4 of 5
Student Name:_______________________________
IV5
ID#:__________________________________
Section J: Identity and Statement of Purpose (TO BE SIGNED WITH NOTARY)
If you are unable to appear in person at Kutztown University to verify his or her identity, the student must provide:
(a) A copy of the valid government-issued photo identification that is acknowledged in the notary statement below, such as but
not limited to a driver’s license, other state-issued ID, or passport; (A Kutztown University ID is not acceptable); and
(b) The original notarized Statement of Educational Purpose provided below.
Statement of Educational Purpose
I certify that I _______________________________________am the individual signing this Statement of Educational Purpose
(Student Print Name)
and that the federal student financial assistance I may receive will only be used for educational purposes and to pay the cost of
attending Kutztown University for 2016-2017.
___________________________________________
Student’s Signature
Date
Notary’s Certificate of Acknowledgement
State of ____________________________________________________________________________________
City/County of _______________________________________________________________________________
On ____________________________, before me, __________________________________________________
(Date)
(Notary’s Name)
personally appeared, _________________________________________________________, and provided to me
(Printed Name of Signer)
on basis of satisfactory evidence of identification ___________________________________________________
(Type of government-issued photo ID provided)
to be the above-named person who signed the forgoing instrument.
WITNESS my hand and official seal
________________________________________________
(seal)
(Notary Signature)
My commission expires on _______________________
(Date)
Please mail this form to:
Financial Aid Services, Kutztown University, P.O. Box 730, Kutztown, Pennsylvania, 19530
(Will not be accepted if faxed or emailed)
Page 5 of 5