2016-2017 Verification Worksheet
Student Name: ________________________________________
Student I. D. Number: _______________________________
Permanent Address: ____________________________________________________________________________________________
Street Address
City
State
Zip
Phone Number: _______________________ Preferred Email: _______________________
Will you be attending classes in the Summer 2016 semester?
□ Yes □ No
(you must complete a Summer Aid Request Form to be considered for Summer Financial Aid).
Verification:
Checklist:
Your financial aid application has been selected for review.
Please provide us with all requested information within 30
days. Include the student’s name and student ID on all
documents to ensure proper identification. Further information
about the Verification process can be found on the 2016-2017
Verification Information Fact Sheet.
□ Complete all sections of the Verification Worksheet and sign.
□ Obtain and attach all 2015 Federal IRS Tax Return Transcripts.
Provide copies of all W2’s if required. A Federal IRS Tax Return
Transcript can be obtained by visiting www.irs.gov or by calling
1-800-908-9946.
□ Collect and submit any other required documentation.
□ Submit all information to the Student Financial Aid Office.
SECTION 1: HOUSEHOLD INFORMATION
DEPENDENT STUDENT: List the people in your parents’ household. Include yourself (the student); your parents; your parents’ other
children if your parents will provide more than half of their support between July 1, 2016– June 30, 2017; and any other people that now
live with your parents if your parents will provide more than half of their support, and will continue to provide more than half their
support between July 1, 2016 – June 30, 2017.
Definition of Parent: A parent is defined as the biological or adoptive parent(s) of the student. If parents are married to each other, both
parents’ information must be included. If parents are not married to each other but still live together in the same household, both parents’
information must be included. If the student’s parents are divorced or separated, use the information for the parent the student lived with
more during the past 12 months. If that parent is remarried, the data must include the stepparent’s information. A legal guardian,
grandparent, or foster parent is not considered a parent unless they have legally adopted the student.
INDEPENDENT STUDENT: List the people in your household. Include yourself; your spouse; your children if you will provide more
than half their support between July 1, 2016 – June 30, 2017; and any other people that now live with you and you provide more than half
their support, and will continue to provide more than half their support between July 1, 2016 – June 30, 2017.
Please read guidelines above before completing.
Student’s Name
Date of Birth
Household Member’s Name
Date of Birth
Relationship to Student
Name of college they will attend at
least half time during 2016-2017 (if
applicable)
SECTION 2: TAX FILING STATUS
Student & Spouse Filing Status (all students)
Parent/Stepparent(s) Filing Status (dependent
students only)
□ I completed my 2015 federal income tax return.
If you filed a joint federal tax return with a spouse,
attach all copies of your and your spouse’s 2015 W2’s.
□ My parents completed their 2015 federal income
tax return. If your parents filed a joint federal tax
return, attach all copies of their 2015 W-2’s
□ I’m not going to file a 2015 federal income tax
return. However, in 2015, I earned:
$_______________. Attach all copies of your and
your spouse’s (if applicable) 2015 W-2’s.
□ My parents are not going to file a 2015 federal
income tax return. However, in 2015 my parents
earned: $_______________. Attach all copies of
your parent’s 2015 W-2’s.
□ I’m not going to file a 2015 federal income tax
return, and I did not work in 2015.
□ My parents are not going to file a 2015 federal
income tax return and did not work in 2015.
*DEPENDENT STUDENT: Obtain and submit a copy of your and your parents/stepparents’ 2015 Federal IRS Tax
Return Transcript. If your parents/stepparents filed Married Filing Jointly, provide copies of all 2015 W-2 forms from all
employers.
*INDEPENDENT STUDENT: Obtain and submit a copy of your and your spouse’s 2015 Federal IRS Tax Return
Transcript. If you are married and filed your tax return as Married Filing Jointly, provide copies of all 2015 W-2 forms
from all employers.
A Federal IRS Tax Return Transcript can be obtained online or by mail free of charge by visiting www.irs.gov or by calling
1-800-908-9946. Be sure to request a “Return Transcript” and not an “Account Transcript.”
If you or your parent/stepparent has a Tax Extension, you may submit IRS form 4868 and all related 2015 W2’s.
If you or a parent/stepparent has business income, you may submit a 2014 Federal IRS Tax Return Transcript.
We will then estimate your 2015 tax information. You must then provide a copy of a 2015 Federal IRS Tax
Return Transcript once you or your parent/stepparent completes your taxes, no later than October 31, 2016.
State tax documents and electronically filed tax returns (Form 8453 and 8879) cannot be accepted.
SECTION 3: UNTAXED INCOME INFORMATION
Do not leave any question in this section blank. Enter “0” or “NA” if no income was received from one of the
sources listed below. If any amount is entered other than “0” or “N/A”, documentation is required.
Student/Spouse
$__________
Additional Income Information
For Calendar Year 2015
(Provide documentation if any amount entered other than “0” or “N/A”)
Military Combat Pay or Special Combat Pay that was taxable
(FOR MILITARY VETERANS ONLY). Only include amount that was taxable
and included in your Adjusted Gross Income. Combat pay is reported on your
2015 W-2 in Box 12, letter Q.
Parent(s) or
Stepparent
$__________
Documentation Required: Copy of 2015 W-2 from employer where you earned
combat pay.
Child support paid because of divorce or separation. Don’t include support for
children in your (or your parents’) household.
$__________
$__________
Documentation Required: Statement from the Bureau of Child Support, or signed
statement from the parent who received the payments. Documentation must
include the names and ages of the children, and the total amount received for
each child in 2015.
Taxable earnings from Federal Work Study or other need-based work programs.
Documentation Required: Copy of 2015 W-2 from employer where you earned
Federal Work Study.
$__________
$__________
$__________
Earnings from work under a cooperative education program. Enter here any
amounts you earned from work under a cooperative education program offered by
an institution of higher education. Do not include Federal Work Study or
Graduate Assistantships.
$__________
Documentation Required: Copy of 2015 W-2 from employer of your co-op and
documentation from your college showing your job was a co-op.
Student grant, scholarship, and fellowship aid, including AmeriCorps awards
reported to the IRS in your (or your parents’) 2015 Federal Tax Return.
$__________
Student/Spouse
$__________
$__________
Documentation Required: Signed copy of 2015 Federal Tax Return with all pages
and schedules, showing amount reported in scholarships and grants.
Untaxed Income Information
For Calendar Year 2015
(Provide documentation if any amount entered other than “0” or “N/A”)
Child Support received for all children. Don’t include foster care or adoption
payments.
Documentation Required: Statement from the Bureau of Child Support, or signed
statement from the parent who made the payments. Documentation must include
the names and ages of the children, and the total amount paid for each child in
2015.
Federal Nutrition Assistance Program (SNAP) received by any member of the
household.
$__________
$__________
$__________
Parent(s) or
Stepparent
$__________
$__________
Documentation Required: Statement from the agency that issued the SNAP
benefit or other documentation that includes the amount received in 2014 or 2015.
Payments to tax-deferred pension and/or savings plans (paid directly or withheld
from earnings), including but not limited to amounts reported on the 2015 W-2
Form in box 12 codes D,E,F,G,H, & S.
Documentation Required: Copy of 2015 W-2 from employer(s) where you made
payments to a tax-deferred pension.
Housing, food, and other living allowances paid to members of the military,
clergy, and others (including cash payments and cash value of benefits).
$__________
$__________
$__________
Documentation Required: Copy of 2015 W-2 from employer(s).
Veteran’s non-education benefits such as Disability, Death Pension, or
Dependency & Indemnity Compensation (DIC) and/or VA Educational WorkStudy allowances.
$__________
$__________
Documentation Required: Statement showing amount received in 2015.
Untaxed portions of IRA Distributions reported on 2015 Federal tax return (Line
15a-15b on 1040, or Line 11a-11b on 1040a). Please check box if this was a
rollover.
$__________
Rollover
$__________
If this was a rollover, please mark box provided.
Untaxed portions of Pension & Annuities reported on 2015 Federal tax return
(Line 16a-16b on 1040, or Line 12a-12b on 1040b). Please check box if this was
a rollover.
Rollover
$__________
Rollover
$__________
Rollover
If this was a rollover, please mark box provided.
Any other untaxed income or benefits not reported elsewhere. Examples include
but are not limited to: worker’s compensation, untaxed portions of railroad
retirement benefits, Black Lung Benefits, disability, money received or paid on
applicant’s behalf, and combat pay not included in AGI on tax return (tax filers
only).
DO NOT INCLUDE student aid, Earned Income Credit, Additional Child Tax
Credit, TANF (welfare) payments, untaxed Social Security benefits, Supplemental
Security Income (SSI), Workforce Investment Act (WIA) educational benefits,
combat pay, benefits from flexible spending arrangements (e.g., cafeteria plans),
foreign income exclusion, or credit for federal tax on special fuels.
Documentation Required: Statement from the agency providing the funds.
Combat pay is reported on 2015 W-2 in Box 12, letter Q.
$__________
SECTION 4: SOURCES OF INCOME STATEMENT
You must complete this section if you are the parent/stepparent of a dependent student, and the income you
earned during 2015 was $20,000 or less. Use the chart below to report all 2015 income or assistance received
from friends, relatives, or any other resource.
EXPENSES
TOTAL ASSISTANCE RECEIVED
SOURCE OF ASSISTANCE
Housing
Food
Personal (clothing)
Other (miscellaneous)
Total amount received in 2015
Please provide a detailed explanation of your income during 2015. The explanation must include how expenses such as
housing, food, utilities, etc. were paid throughout the year. Please add additional sheets if necessary.
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
Name of parent writing statement: _________________________________________________________________
SECTION 5: SIGNATURES
This form must be signed by the student and spouse (if independent and married), or by the student and at least
one parent (if dependent).
By signing this application, you hereby affirm that all information reported on this form and any attachment hereto is true,
complete, and accurate to the best of your knowledge. If asked by an authorized official, you agree to provide additional proof of
information provided on this form. You understand that the Student Financial Aid Office at Kent State University will correct
the FAFSA application, as necessary, based on the information submitted. You agree that you understand that if you received
federal student aid based on incorrect information, you will need to repay it. You may also be required to pay fines and fees. By
signing below, you certify that you (1) will use federal and/or state student financial aid only to pay the cost of attending an
institution of higher education, (2) are not in default on a federal student loan or have made satisfactory arrangements to repay it,
(3) do not owe money back on a federal student grant or have made satisfactory arrangements to repay it, (4) will notify your
college if you default on a federal student loan and (5) will not receive a Federal Pell Grant from more than one college for the
same period of time.
_______________________________________________________________ _____________________
Student Signature
Date
_______________________________________________________________ _____________________
Student’s Spouse Signature (if applicable)
Date
______________________________________________________________ _____________________
Parent/Stepparent Signature (if student is dependent)
Date
PO Box 5190
STUDENT FINANCIAL AID OFFICE
Kent, OH 44242-0001 330-672-2972
FAX 330-672-4014
www.kent.edu/financialaid
finaid@kent.edu
VF-VFWKST-17