FORM V1
Dependent
2016-2017 Verification Worksheet
Dependent Student
Your FAFSA application was selected for a review process called verification. The law requires us to ask
you for information prior to awarding federal aid. In this process, UTPB will be comparing information
provided on this form, and possibly other requested documents, with the information you provided on
your Free Application for Federal Student Aid (FAFSA). If there are any differences, your FAFSA
information may be corrected by this office. Students selected for verification will not be eligible for
federal aid until a completed package is submitted. Please complete all required sections of this form,
failure to complete any of the required sections make cause delays in the processing of financial aid.
A. Student Information
Last Name
First Name
M.I.
Address (include apt. no.)
City
Social Security Number
Date of Birth
State
Home Phone (include area code)
Zip Code
Cell Phone (include area code)
Email Address
UTPB ID# (if known)
HomeB.
Phone
(includeinarea
code)
Number
Household



List below the people in your household that your parents will support between July 1, 2016 and June 30, 2017
Include yourself, parents, siblings, or others who live with you, for whom your parents will provide more than 50% of their support.
(This may include children who do not reside in the household) between July 1, 2016 and June 30, 2017
List anyone in your household who will be, or is currently attending college at least half-time in a degree or diploma program at a
postsecondary educational institution.
Full Name
Age
Relationship
Self
College/University
Enrolled at least
half-time (Y/N)
UTPB
INSTRUCTIONS FOR IRS DATA RETRIEVAL TOOL
The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If you have not already used
the tool, go to FAFSA.gov, log in to your FAFSA record, select “Make FAFSA Corrections,” and navigate to the Financial Information
section of the form. From there, follow the instructions to determine if you are eligible to use the IRS Data Retrieval Tool to transfer
2015 IRS income tax information into your 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 see your financial aid administrator.
If the student and spouse filed separate 2015 IRS income tax returns, the IRS DRT cannot be used and the 2015 IRS Tax Return
Transcript(s) must be provided for each. Student can order transcript online at www.irs.gov or can call 1-800-908-9946. Transcripts
will arrive by mail within 5-10 business days.
SSN#
Student Name:
C. Student
Student
Name Income Section
Important Note: If you filed, or will file an amended 2015 IRS tax return, UTPB Financial Aid will also require that you submit a Tax
Account Transcript along with the Tax return Transcript.
Student Tax return Filers-Complete this section if you filed or will file a 2015
Tax return. Check the option below that you will use to supply tax information
Did you, the student, file taxes for the 2015 year?
I, the student, have used the IRS Retrieval Tool used to transfer my
information and submitted the corrected FAFSA for processing. Please tell us
what date you completed this step.
Yes. Complete accompanying Section.
No. Skip to Section D
I, the student, am unable or choose not to use the IRS Retrieval
Tool, and I will submit a 2015 IRS Tax Return Transcript. Copies of the Tax
return are not acceptable forms for verification purposes.
Do not return this worksheet without an Official
2015 Tax Transcript attached, if this was the option
you selected.
D.
Student Tax Return Non Filers: Complete this section if the student will not file/not required to file a 2015 IRS Tax Return
E.
F.
I, the
H.student, was NOT employed and had no incomeI. earned from work in 2015.
K.
L.
G.
J.
M.
I, the student (and/or my spouse) was employed in 2015. List below the names of employers, the amount earned from working, and
N.whether
nt Tax
return Non-Filers: Complete this section if you will not/are not required to file 2012 Taxes
an IRS W-2 form was provided. Please provide copies of all 2015 IRS W-2 forms issued. List every employer even if the employer
did not issue a W-2 form
Employer Name
2015 Amount Earned
IRS W2 Provided
E. Parent Income Section
Important Note: If you filed, or will file an amended 2015 IRS tax return, UTPB Financial Aid will also require that you submit a Tax
Account Transcript along with the Tax return Transcript.
Parent Tax return Filers-Complete this section if you filed or will file a 2015
Did you, the parent, file taxes for the 2015 year?
Tax return. Check the option below that you will use to supply tax
information
Yes. Complete accompanying Section
No. Skip to Section F
Do not return this weorksheet without an Official
2015 Tax Return Transcript, if this was the option
you selected
I, the parent, have used the IRS Retrieval Tool used to transfer my
information and submitted the corrected FAFSA for processing. Please tell us
what date you completed this step.
I, the parent, am unable or choose not to use the IRS Retrieval
Tool, and I will submit a 2015 IRS Tax Return Transcript. Copies of the Tax
return are not acceptable forms for verification purposes.
I, the parent, was employed in 2015. List below the names of employers, the amount earned from working, and whether an IRS W-2 form
was provided. Please provide copies of all 2015 IRS W-2 forms issued. List every employer even if the employer did not issue a W-2 form
Students/Parents who are unable to link or choose not to use the IRS Retrieval Tool will be required to submit a 2015 Tax Transcript from
the IRS. Students and Parents can order transcripts online at www.irs.gov or can call 1-800-908-9946. Ordered transcripts will arrive by
mail within 5-10 business days. UTPB also recommends visiting your local IRS Tax office to pick up transcripts in person. A link to area
office in Texas can be found in the verification section of the financial aid page at www.utpb.edu
Student Name: ___________________________________________
F.
SSN#________________________________
Parent Tax Return Non Filers: Complete this section if the student will not file/not required to file a 2015 IRS Tax Return
Employer Name
2015 Amount Earned
IRS W2 Provided
Neither parent was employed nor had income earned from work in 2015, and one or both parents had money paid on their behalf or
received untaxed income to support the household
If you selected the last option you MUST complete the student section of the LOW INCOME VERIFICATION FORM. This form records amounts of
monies received to cover the cost of living. This form is not included with this worksheet, to print this form you must go to ss.utpb.edu/financial-aid/
and click on verification on the left side tool bar. Failure to include this form may cause delays in the processing of your financial aid.
G. Additional Household Information
Did anyone in your household receive Supplemental Nutrition Assistance Program (SNAP/Food Stamps) benefits in
2014 and/or in 2015?
No
Yes
If you selected yes, you are required to complete the parent section (A) of the
verification of SNAP Benefits Form (FORM V2) attached to the back of the
verification packet.
Did either parent pay child support in 2015?
No
Yes
If you selected yes, you are required to complete the verification of Child
Support Form (FORM V3) attached to the back of the verification packet.
H. Certification and Signature
I certify that
is completed and correct. SignaturesQ.
from the student and at least one parent
O. all of the information reported on this worksheet
P.
whose information
was used on the FAFSA are required.
R.
S.
T.
U.
V.
W.
WARNING:
If youTaxes
purposely give false
X. nt Tax return Non-Filers: Complete this section if you will not/are not required
to file 2012
Student Signature
Date
Parent Signature
Date
or misleading information, you may be
fined, sentenced to jail, or both.
Please contact the UTPB Office of Financial Aid if you have any questions about the information asked about on this form
FORM V2
2016-2017 Verification of SNAP Benefits
You have been selected by the Department of Education to verify the receipt of SNAP benefits sometime during
2014 or 2015. This form serves as verification that you and/or your parents (if dependent) received benefits from
the Supplemental Nutrition Assistance Program (SNAP), which was formerly known as the Food Stamp Program.
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 (1800-433-3243).
For SNAP verification purposes the household includes:
DEPENDENT STUDENTS


The Parents (including a stepparent)
The student and other siblings (even if they
don’t reside with the parent
 Other children if parents will provide more
than 50% of their support from July 1, 2016June 30, 2017
 Other people if they in the household and
the parents will provide more than 50% of
their support from July 1, 2016-June 30, 2017
INDEPENDENT STUDENTS



The Student and Spouse (if married)
Your Children
Other children if you will provide more than
50% of their support from July 1, 2016 - June
30, 2017
 Other people if they now live with you and
you will provide more than 50% of their
support from July 1, 2016 - June 30, 2017
(A) Parent Section:
Yes. Someone in the household, as described above, received SNAP benefits
No. No one in the household received SNAP benefits
(B) Student Section:
Yes. Someone in the household, as described above, received SNAP benefits
No. No one in the household received SNAP benefits
Note: If we have reason to believe that the information regarding the receipt of SNAP benefits is inaccurate, we may require
documentation from the agency that issued the SNAP benefits in 2014 or 2015
Certification and Signature:
Each person signing below certifies that all of the
information reported is complete and correct. The student
and at least one parent (if dependent) whose information
was reported on the FAFSA, must sign and date.
Student Signature
Date
Parent Signature (if dependent)
Date
WARNING: If you purposely give false or
misleading information, you may be
fined, sentenced to jail, or both.
UTPB ID (if known)
FORM V3
2016-2017 Verification of Child Support Paid
Please verify the child support paid by you and/or your spouse or your parents, if you are a dependent
student based on the FAFSA. Please complete and submit to the Office of Financial Aid.
Please complete the chart below. Indicate $0 if no child support was paid.
Name of person who
paid child support
Name of person to
whom child support
was paid
Name of Child for
whom support was paid
Amount of child
support paid in 2015
Note: If we have reason to believe that the information regarding child support paid is not accurate, we
may require additional documentation, such as:



A copy of the separation agreement or divorce decree that shows the amount of child support to be provided
A statement from the individual receiving the child support certifying the amount child support to be
provided
Copies of the child support payment checks or money order receipts
Certification and Signature:
WARNING: If you purposely give false or
misleading information, you may be
fined, sentenced to jail, or both.
Each person signing below certifies that all of the
information reported is complete and correct. The student
and at least one parent (if dependent) whose information
was reported on the FAFSA, must sign and date.
Student Signature
Date
Parent Signature (if dependent)
Date
UTPB ID (if known)