OFFICE OF FINANCIAL AID
2016-2017 Dependent Verification
Form STUDENT NAME: _____________________________________
ID#:__________________
Family Information
Please Include:
• Yourself
• Your parent(s) (including step-parents)
• Your parent(s) other dependent children if a) your parent(s) will provide more than half of their support from July 1, 2016 through
June2017, or b) the children would be required to provide parental information when applying for Federal Student Aid
30,
• Other people only if they now live in your parent household and your parents will provide more than half of their support from July 1,
2016 through June 30, 2017
Full Name
Age
□ I filed a 2015 Federal Tax Return
Relationship
Name of College (If at least half-time 2016-2017)
Self
Rose-Hulman
Parent’s 2015 Income Information
□ I used IRS data retrieval
□ I did not use IRS data retrieval and am attaching a copy of my tax return transcript
□ My spouse and I filed separate tax returns, we are attaching copies of both tax return transcripts
□ I did not file a 2015 Federal Tax Return.
OR
If you were not required to file a return but worked in 2015 list all employers and amounts earned below. Please note that if IRS law
requires you to file a federal tax return, we cannot take further action on your application for federal student aid until you furnish us a
copy of your tax return transcript.
Complete the following table only if you are a non-tax filer.
In the table below, please provide information for the parent(s) listed on the FAFSA that was employed in 2015 but will not and is not
required to file a 2015 income tax return. List the names of the employers, the amount earned from each employer in 2015, and whether
an IRS W-2 is attached. List every employer even if they did not issue and IRS W-2. If more space is needed, attach a separate page with
the student’s name and ID #.
Employer
Wages (Box 1 on Form W-2, If
a W-2 was not received, list
all earnings for the job)
MOTHER/
$
$
$
$
$
STEP-MOTHER
$
FATHER/
STEP-FATHER
W-2
Attached
Y or N
2016-2017 Dependent Verification Form
STUDENT NAME: _____________________________________
ID#:_____________________
_ Student’s 2015 Income Information
□ I filed a 2015 Federal Tax Return
□ I used IRS data retrieval
□ I did not use IRS data retrieval and am attaching a copy of my tax return transcript
OR
□ I did not file a 2015 Federal Tax Return.
If you were not required to file a return but worked in 2014 list all employers and amounts earned below. Please note that if IRS law
requires you to file a federal tax return, we cannot take further action on your application for federal student aid until you furnish us a
copy of your tax return transcript.
Complete the following table only if you are a non-tax filer.
For the student who is not required to file a 2015 income tax return, in the table below list the names of the employers, the amount
earned from each employer in 2015, and whether an IRS W-2 is attached. List every employer even if they did not issue and IRS
W-2. If more space is needed, attach a separate page with the student’s name and ID #.
Wages (Box 1 on Form W-2,
If a W-2 was not received,
list all earnings for the job)
Employer
W-2
Attached
Y or N
$
$
Student
$
Federal Benefits
Complete this section if you or someone in your household (listed above in the family section) received benefits from the Supplemental
Nutrition Assistance Program or SNAP (formerly known as food stamps).
□ One of the persons listed in the family information section received SNAP benefits in 2014 or 2015.
documentation of the receipt of SNAP benefits.
If asked, I will provide
Child Support Paid
Complete this section if child support was paid because of divorce or separation or as a result of a legal requirement. Do not include
support paid for children listed in the parents’ household as reported above.
Name of Person Who Paid
Support
Name of Person Who Received
Support
Name of Child
Amount of Child Support
Paid in 2015
Certification and Signatures
Each person signing this worksheet certifies that all the information reported on it is complete and correct. The student and one parent
must sign and date.
__________________________________________________
Student’s Signature
___________________________________
Date
__________________________________________________
Parent’s Signature
___________________________________
Date
Submit this worksheet to:
Rose-Hulman Institute of Technology
Financial Aid Office
5500 Wabash Ave
Terre Haute, IN 47803
Fax: 812-877-8838
Email: finaid@rose-hulman.edu
WARNING: If you purposely give false or
misleading information on this worksheet, you
may be fined, be sentenced to jail or both.