Office Use Only: Ready for Review Initial: _________ Date:____________ Rechecked File: _______ Date: ______ Office Use Only: Initial: ________ Trans #: ________ Verified: ____/____/____ Change No Change Original EFC: ________ New EFC: ________ 2015-2016 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 ______________________________________________________ ___________________________ ___________________________________________________________________ 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 Student’s Last Name Student’s First Name Student’s M. I. Kutztown University Student’s ID or SSN 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, 2015 and June 30, 2016 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, 2015 and June30, 2016. 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, 2015 and June 30, 2016, 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 ID# or SSN:__________________________________ Section C: Tax Forms and Income Information (student and spouse) 1. TAX RETURN FILERS Instructions: Complete this section if the student and/or spouse filed or will file a 2014 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 2014 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 2014 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 2014 IRS tax return transcript(s) – we cannot accept a photocopy of the income tax return. To print a PDF copy of your IRS tax return transcript go to http://www.irs.gov/Individuals/Get-Transcript and click on “Get Transcript ONLINE.” Click on the link to “Create an Account.” Once you enter your information, you will receive a confirmation code in your email. Enter the code into the IRS website and click to verify. Once the code is verified, follow the steps and answer the questions to proceed. You will be able to choose a reason for needing the transcript. If you click on “Higher Education/Student Aid,” the screen changes to suggest that you get a tax return transcript. Select the “2014 Return Transcript.” Print and send it to us. 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 2014 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 2014 tax year. Student and/or Spouse filed or will file an amended 2014 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 2014 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 2014 federal income tax return. Student Student’s Spouse B. If you or your parent did not file and are not required to file, list below you and/or your parent(s) employers, the amount earned from each employer in 2014, and whether a W-2 form is attached. Please submit a copy of your W-2 forms to Financial Aid Services. If no income for 2014, put “0.” Do not leave blank. Student’s Employer(s) Amount(s) W-2s Attached Yes Parent’s employer(s) Pro Auto Amount(s) $ .00 $ $ 980 .00 $ .00 $ .00 $ .00 $ .00 $ 1,280 ABC Shipping Page 2 of 5 W2s Attached Yes Student Name:_______________________________ Section D: SNAP and Child Support Paid 1. ID# or SSN:__________________________________ One of the persons listed in your household received SNAP (Supplemental Nutrition Assistance Program) benefits in 2013 or 2014. Yes 2. IV5 No You (or if marred, your spouse) paid child support in 2014. 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 2014 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 2014 or enter “0” if the answer is “none” for sections D and E. Do not leave any item blank. Section E: 2014 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: 2014 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# or SSN:__________________________________ 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 2015-2016. _______________________________________ _________ Student’s Signature Date _________ _________ FAO Initials 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# or SSN:__________________________________ 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 2015-2016. ___________________________________________ 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) My commission expires on _______________________ (Notary Signature) (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