VERFIND16
Return all pages to: NCC Financial Aid Office
3835 Green Pond Road, Bethlehem, PA 18020-7599
Or fax: 610-861-4565
2016-2017 Dependent Verification Worksheet
SECTION A: STUDENT INFORMATION
NCC Student ID:
Name:
SSN:
Phone:
Your application has been selected for verification. We are required by federal law (34 CFR, Part 668) to compare the information from your
Free Application for Federal Student Aid (FAFSA) with the information provided on this form.
Complete all sections and sign this form, INCOMPLETE FORMS WILL BE RETURNED
 We will update your FAFSA, if needed, based on the information provided on this form.
 We cannot continue processing your financial aid until all required financial aid documents have been submitted.
SECTION B: HOUSEHOLD INFORMATION
List the people in your parent(s)’ household in the chart below. Include:
•
•
Yourself
Your parent(s):
 If your legal parents (your biological and/or adoptive parents) are married to each other, or are not married but
live together, list both below.
 If your legal parent has married/remarried, list your legal parent and your stepparent below.
 If your legal parents are separated or divorced, list only the parent whose information you provided on the
FAFSA.
• List your parent(s)’ other children below if your parent(s) will provide more than half of their support from July 1, 2016
through June 30, 2017 or if the children would be required to provide parental information if they were completing a
2016-2017 FAFSA.
• List other dependents only if they now live with your parent(s) AND get more than half of their support from your
parent(s) AND will continue to get this support from July 1, 2016 through June 30, 2017.
• Attach a separate sheet if you need more space for additional household members.
Age
Relationship
College
Write the age of each
Write the relationship of
For those listed below (excluding parents) who will be attending
family member in the
each family member to the
college between July 1, 2016 and June 30, 2017 AND will be
chart below
student in the chart below
enrolled at least half-time in a program that leads to a college
degree or certificate, list the name and state of the college.
Full Name (Household Member)
Age
Relation to Student
Self
Name and State of College
(if not in college write N/A)
Northampton Community College, PA
PLEASE READ: Instructions for completing Sections C and D: If you are/were required to file a 2015 Federal Tax Return you must
provide tax information obtained directly from the IRS by either using the IRS Data Retrieval Tool (within the FAFSA) to transfer
your 2015 Federal Tax Return information into your FAFSA or by providing a 2015 Tax Return Transcript available from the IRS
at www.irs.gov. COPIES OF YOUR TAX RETURN ARE NOT ACCEPTABLE. You can request the Tax Return Transcript be sent to you
by mail (takes 5 to 10 calendar days). Make sure to request the “IRS Tax Return Transcript” and not the “IRS Tax Account
Transcript.” You will need the Social Security Number (or the IRS individual taxpayer identification number) and the date of birth
of the first person listed on the 2015 IRS income tax return, and the address on file with the IRS (normally this will be the address
used on the 2015 IRS income tax return).If you are not required to file but had earned income in 2015 you must provide a copy of
all W2 form(s) you received from employer(s).
SECTION C: STUDENT FINANCIAL INFORMATION
Student Name:
Check the ONE box that applies to you (the student) for 2015:
I (the student) filed or will file a 2015 IRS Federal Income Tax Return and (see instructions above):
 I have used or will use the IRS Data Retrieval Tool through FAFSA to provide my tax information;
or
 I have or will provide a 2015 IRS 2014 IRS Tax Return Transcript
I did not work in 2015 and had no earned income.
I was not required to file taxes because my earned income was below the tax filing limit.
You must attach a copy of the IRS Form W2 for each source of employment income received for tax year 2015 and you
must complete the information in the table below.
Did you attach copy of IRS W-2?
Employer’s Name
2015 Amount Earned Did Employer provide IRS W-2?
Susie’s Auto Body (Example)
$500.00
Yes
Yes
SECTION D: PARENT FINANCIAL INFORMATION
PARENT 1 Name:
Relationship to Student:
PARENT 2 Name:
Relationship to Student:
Check the ONE box that applies to your Parent(s) for 2015:
I (the parent(s)) filed or will file a 2015 IRS Federal Income Tax Return and (see instructions above):

I have used or will use the IRS Data Retrieval Tool through FAFSA to provide my tax information. Married
parents who file separately are not eligible to use the IRS Data Retrieval Tool and must provide an IRS Tax
Return Transcript for each parent;

I have or will provide a 2015 IRS 2015 IRS Tax Return Transcript. Parents who file separately must provide an
IRS Tax Return Transcript for each parent.
or
I (the parent(s)) did not work in 2015 and had no earned income.
I (the parent(s)) was not required to file taxes because my earned income was below the tax filing limit.
You must attach a copy of the IRS Form W-2 for each source of employment income received for tax year 2015 and you
must complete the information in the table below.
Employer’s Name
Susie’s Auto Body (Example)
2015 Amount Earned
$500.00
SECTION E: VERIFICATION OF SNAP BENEFITS
Did Employer provide IRS W-2?
Yes
Did you attach copy of IRS W-2?
Yes
Did you, your parent(s) or anyone listed in your household in Section B receive SNAP benefits during the calendar
years 2014 or 2015?
The parents’ household includes:
 The student.
 The parents (including a stepparent) even if the student doesn’t live with the parents.
 The parents’ other children if the parents will provide more than half of the children’s support from July 1, 2016, through
June 30, 2017, or if the other children would be required to provide parental information if they were completing a FAFSA for
2016–2017. Include children who meet either of these standards even if the children do not live with the parents.
 Other people if they now live with the parents and the parents provide more than half of the other people’s support and will
continue to provide more than half of their support through June 30, 2017.
Check one:
NO SNAP Benefits were received during 2014 or 2015.
YES SNAP Benefits were received during 2014 or 2015 (Complete section below.)
The following member of the parents’ household: _____________________________________________ received
(name of SNAP recipient)
benefits from the Supplemental Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program)
sometime during 2014 or 2015. SNAP may be known by another name in some states. For assistance in determining
the name used in a state, please call 1-800-4FED-AID (1-800-433-3243).
SECTION F: VERIFICATION OF CHILD SUPPORT PAID
Did the student or student’s parent(s) listed in Section B pay child support because of divorce or separation
or as a result of a legal requirement during the calendar year 2015?
DO NOT INCLUDE CHILD SUPPORT FOR CHILDREN LISTED IN YOUR HOUSEHOLD IN SECTION B – ONLY FOR OTHER CHILDREN
LIVING OUTSIDE OF YOUR HOUSEHOLD. DO NOT REPORT CHILD SUPPORT RECEIVED FOR CHILDREN LIVING IN YOUR HOUSEHOLD
IN SECTION B.
Check one:
NO child support was paid for 2015.
YES child support was paid for 2015. (Complete section below.)
List below the names of the persons who paid the child support, the names of the persons to whom the child support
was paid, the names and ages of the children for whom the child support was paid, and the total annual amount of
child support that was paid in 2015 for each child. If more space is needed, provide a separate page that includes the
student’s name and ID number at the top.
Name of Person Who
Name of Person to
Name of Child for Whom
Age of Child
Amount of
Paid Child Support
Whom Child Support
Support Was Paid
for Whom
Child Support
was Paid
Support Was
Paid in 2015
Paid
SECTION G: CERTIFICATIONS AND SIGNATURES
Each person signing below certifies that all of the information reported is complete and correct. The student and one
parent whose information was reported on the FAFSA must sign and date.
WARNING: If you purposely give false or
misleading information you may be fined, be
sentenced to jail, or both.
________________________________________
Print Student’s Name
________________________________________
Student’s Signature
___________________________
Date
________________________________________
Print Parent’s Name
________________________________________
Parent’s Signature
___________________________
Date
Information for Individuals with Unusual Circumstances
Individuals Granted a Filing Extension by the IRS
If an individual is required to file a 2015 IRS income tax return and has been granted a filing extension by the IRS, provide the
following documents:
 A copy of IRS Form 4868, ‘‘Application for Automatic Extension of Time to File U.S. Individual Income Tax Return,’’ that was filed
with the IRS for tax year 2015;
 A copy of the IRS's approval of an extension beyond the automatic six-month extension if the individual requested an additional
extension of the filing time for tax year 2015; and
 A copy of IRS Form W–2 for each source of employment income received for tax year 2015 and, if self-employed, a signed
statement certifying the amount of the individual’s Adjusted Gross Income (AGI) and the U.S. income tax paid for tax year 2015.
Individuals Who Filed an Amended IRS Income Tax Return
If an individual filed an amended IRS income tax return for tax year 2015, provide both of the following:
 A copy of the 2015 IRS Tax Return Transcript; and
 A signed copy of the 2015 IRS Form 1040X, “Amended U.S. Individual Income Tax Return,” that was filed with the IRS.
Individuals Who Were Victims of IRS Identity Theft
 A victim of IRS identity theft who is not able to obtain a 2015 IRS Tax Return Transcript or use the IRS DRT must contact the IRS
at 1-800-908-4490. Upon authentication of the tax filer’s identity, the IRS will provide, by U.S. Postal Service, a printout of the
tax filer’s 2015 IRS income tax return information.
Individuals Who Filed Non-IRS Income Tax Returns

An individual who filed or will file a 2015 income tax return with Puerto Rico, another U.S. territory (e.g., Guam, American
Samoa, the U.S. Virgin Islands, the Northern Marianas Islands), or with a foreign country, must provide a signed copy of that
2015 income tax return(s).