2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
YOU MUST HAVE ACCESS TO A PRINTER IN ORDER TO PRINT AND SUBMIT THIS FORM
Your FAFSA was selected for review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm
the information you reported on your FAFSA. THIS DOCUMENT IS A FORM - PLEASE TYPE YOUR INFORMATION IN THE GRAY AREAS PROVIDED. USE THE
“TAB” KEY ON YOUR KEYBOARD TO MOVE TO THE SPACES PROVIDED – DO NOT USE THE “ENTER” KEY.
PLEASE REFER TO THE NOTICE YOU RECEIVED FROM OUR OFFICE TO DETERMINE WHICH SECTION TO COMPLETE
THIS FORM CONTAINS SECTIONS A THRU F. YOU ARE NOT REQUIRED TO COMPLETE ALL SECTIONS
SECTION A:
First Name:
Last Name:
Mailing Address:
City:
Phone:
Email:
SS#: X X X – X X State:
Zip:
HOUSEHOLD INFORMATION:
List the people in the space provided below that your parents will support between July 1, 2015 and June 30, 2016. Include yourself, your parents
(including a step parent), and your parent’s dependent children (if your parents provide more than half their support or if they would be required to give
parental information when applying for Federal Student Aid). Include the name of the college for any household member, excluding your parent(s), who
will be enrolled, at least half time in a degree, diploma, or certificate program at a postsecondary institution.
Name
Age
STUDENT:
Relationship
SELF
College Attending (if applicable)
Western Dakota Tech
Source(s) If $0 income, type below “I had no income in 2014”
IF YOU DID NOT file a 2014 federal income tax return,
mark this box, attach your W-2 forms and COMPLETE
SOURCES OF INCOME SECTION
OR
IF YOU FILED a 2014 federal income tax return, mark this box.
2014 Amount
$
$
NOTE: RIGHT CLICK ON THE NUMBER
TO THE LEFT, AND SELECT
UPDATE FIELD TO TOTAL THE COLUMN
$ 0.00
Source(s) If $0 income, type below “I had no income in 2014”
PARENTS:
2014 Amount
$
$
$
If you DID NOT file a 2014 federal income tax return.
Mark this box, attach your W-2 forms and COMPLETE
SOURCES OF INCOME SECTION
OR
IF YOU FILED a 2014 federal income tax return, mark this box.
NOTE: RIGHT CLICK ON THE NUMBER
TO THE LEFT, AND SELECT
UPDATE FIELD TO TOTAL THE COLUMN
$ 0.00
DO NOT SKIP – THIS INFORMATION IS REQUIRED FOR SECTION A!
Did anyone listed in the Household above received SNAP benefits, formerly known as Food Stamps in 2013 or 2014?
In 2014 child support was paid by someone in the Household?
Name of Person who PAID Child Support
Yes
Yes (Complete Child Support section below)
Name of Person who RECEIVED Child Support
No
No
Name and Age of Child the Support Was For
Total Amt
$
$
If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Our signatures certify this information is correct.
Student Signature
Date
Parent Signature
Date
NOTICE: This form must be submitted to our office within 14 days of this request. If the required documentation is not received, we cannot continue processing your application for financial aid.
Processing will not resume until/unless the necessary information/documents are provided. If the 14-day time period extends to or beyond registration day, you must either pay the institutional costs from
personal funds, or request a payment plan from the Student Accounts Office.
IF YOU WERE REQUIRED TO COMPLETE SECTION A, PLEASE SIGN, DATE AND SUBMIT THIS SHEET ONLY
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.
2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
YOU MUST HAVE ACCESS TO A PRINTER IN ORDER TO PRINT AND SUBMIT THIS FORM
Your FAFSA was selected for review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm
the information you reported on your FAFSA. THIS DOCUMENT IS A FORM - PLEASE TYPE YOUR INFORMATION IN THE GRAY AREAS PROVIDED. USE THE
“TAB” KEY ON YOUR KEYBOARD TO MOVE TO THE SPACES PROVIDED – DO NOT USE THE “ENTER” KEY.
SECTION B:
First Name:
Last Name:
Mailing Address:
City:
Phone:
Email:
SS#: X X X – X X State:
Someone in my household received SNAP benefits, formerly known as Food Stamps in 2013 or 2014?
Zip:
Yes
No
If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Our signatures certify this information is correct.
Student Signature
Date
Parent Signature
Date
NOTICE: This form must be submitted to our office within 14 days of this request. If the required documentation is not received, we cannot continue processing your application for financial aid.
Processing will not resume until/unless the necessary information/documents are provided. If the 14-day time period extends to or beyond registration day, you must either pay the institutional costs from
personal funds, or request a payment plan from the Student Accounts Office.
IF YOU WERE REQUIRED TO COMPLETE SECTION B, PLEASE SIGN, DATE AND SUBMIT THIS SHEET ONLY
SECTION C:
First Name:
Last Name:
Mailing Address:
City:
Phone:
Email:
In 2014 child support was paid by someone in the Household?
Name of Person who PAID Child Support
SS#: X X X – X X State:
Zip:
Yes (Complete Child Support section below)
Name of Person who RECEIVED Child Support
No
Name and Age of Child the Support Was For
Total Amt
$
$
$
If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Our signatures certify this information is correct.
Student Signature
Date
Parent Signature
Date
NOTICE: This form must be submitted to our office within 14 days of this request. If the required documentation is not received, we cannot continue processing your application for financial aid.
Processing will not resume until/unless the necessary information/documents are provided. If the 14-day time period extends to or beyond registration day, you must either pay the institutional costs from
personal funds, or request a payment plan from the Student Accounts Office.
IF YOU WERE REQUIRED TO COMPLETE SECTION C, PLEASE SIGN, DATE AND SUBMIT THIS SHEET ONLY
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.
2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
YOU MUST HAVE ACCESS TO A PRINTER IN ORDER TO PRINT AND SUBMIT THIS FORM
Your FAFSA was selected for review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm
the information you reported on your FAFSA. THIS DOCUMENT IS A FORM - PLEASE TYPE YOUR INFORMATION IN THE GRAY AREAS PROVIDED. USE THE
“TAB” KEY ON YOUR KEYBOARD TO MOVE TO THE SPACES PROVIDED – DO NOT USE THE “ENTER” KEY.
SECTION D:
PLEASE READ THE INSTRUCTIONS FOR THE STATEMENT OF EDUCATIONAL PURPOSE BELOW BEFORE COMPLETING
First Name:
Last Name:
Mailing Address:
City:
Phone:
Email:
SS#: X X X – X X State:
Someone in my household received SNAP benefits, formerly known as Food Stamps in 2013 or 2014?
Zip:
Yes
No
Yes (Complete Child Support section below)
In 2014 child support was paid by someone in the Household?
Name of Person who PAID Child Support
~
Name of Person who RECEIVED Child Support
No
Name and Age of Child the Support Was For
Total Amt
$
$
I previously attended WDT
OR
I am a NEW student - the following will be provided to WDT’s Admissions Office: (Please check (X) one):
A copy of my final official high school transcript that shows the date when my diploma was awarded.
A copy of my General Educational Development (GED) transcript that includes my GED scores.
STOP –You must appear in person to complete this section and present your government issued ID (such as a driver’s license,
military ID, passport) and this form to a WDT Financial Aid staff member, who will validate the statement below at the time of submission by
maintaining a copy of your photo ID and by providing a signature and date.
Statement of Educational Purpose
I certify that I ____________________________________ am the individual signing this Statement of Educational Purpose and that the federal
Print Student’s Name
student financial assistance I may receive will be used only for educational purposes and to pay the cost of attending WDT for 2015–2016.
______________________________________________________
Student’s Signature
Date
_______________________________________________________
WDT Financial Aid Staff’s Signature
Date
If you cannot appear in person at the WDT Financial Aid Office, you must provide a
copy of your government issued photo ID and have this notarized by a public notary.
Notary’s Certificate of Knowledge – Please notarize student’s signature above.
State of ____________________________ City/County of _______________________________ on ______________________ (date) before
me, __________________________________ personally appeared, ________________________________ and provided to me on basis of
Notary’s Name
Printed Name of Signer
satisfactory evidence of identification __________________________ to be the above named person who signed the foregoing instrument.
Type of Government Issued Photo ID Provided
WITNESS my hand and official seal
(SEAL)
___________________________________________ ______________________________
Notary’s Signature
Date Commission Expires
If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Our signatures certify this information is correct.
Student Signature
Date
Parent Signature
Date
NOTICE: This form must be submitted to our office within 14 days of this request. If the required documentation is not received, we cannot continue processing your application for financial aid.
Processing will not resume until/unless the necessary information/documents are provided. If the 14-day time period extends to or beyond registration day, you must either pay the institutional costs from
personal funds, or request a payment plan from the Student Accounts Office.
IF YOU WERE REQUIRED TO COMPLETE SECTION D, PLEASE SIGN, DATE AND SUBMIT THIS SHEET ONLY
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.
2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
YOU MUST HAVE ACCESS TO A PRINTER IN ORDER TO PRINT AND SUBMIT THIS FORM
Your FAFSA was selected for review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm
the information you reported on your FAFSA. THIS DOCUMENT IS A FORM - PLEASE TYPE YOUR INFORMATION IN THE GRAY AREAS PROVIDED. USE THE
“TAB” KEY ON YOUR KEYBOARD TO MOVE TO THE SPACES PROVIDED – DO NOT USE THE “ENTER” KEY.
SECTION E (2 PAGES):
PLEASE READ THE INSTRUCTIONS FOR THE STATEMENT OF EDUCATIONAL PURPOSE BELOW BEFORE COMPLETING
First Name:
Last Name:
Mailing Address:
City:
Phone:
Email:
~
SS#: X X X – X X State:
Zip:
HOUSEHOLD INFORMATION:
List the people in the space provided below that your parents will support between July 1, 2015 and June 30, 2016. Include yourself, your parents
(including a step parent), and your parent’s dependent children (if your parents provide more than half their support or if they would be required to give
parental information when applying for Federal Student Aid). Include the name of the college for any household member, excluding your parent(s), who
will be enrolled, at least half time in a degree, diploma, or certificate program at a postsecondary institution.
Name
Age
STUDENT:
Relationship
SELF
College Attending (if applicable)
Western Dakota Tech
Source(s) If $0 income, type below “I had no income in 2014”
IF YOU DID NOT file a 2014 federal income tax return,
mark this box, attach your W-2 forms and COMPLETE
SOURCES OF INCOME SECTION
OR
2014 Amount
$
$
NOTE: RIGHT CLICK ON THE NUMBER
TO THE LEFT, AND SELECT
UPDATE FIELD TO TOTAL THE COLUMN
$ 0.00
IF YOU FILED a 2014 federal income tax return, mark this box.
Source(s) If $0 income, type below “I had no income in 2014”
PARENTS:
2014 Amount
$
$
$
If you DID NOT file a 2014 federal income tax return.
Mark this box, attach your W-2 forms and COMPLETE
SOURCES OF INCOME SECTION
OR
IF YOU FILED a 2014 federal income tax return, mark this box.
NOTE: RIGHT CLICK ON THE NUMBER
TO THE LEFT, AND SELECT
UPDATE FIELD TO TOTAL THE COLUMN
$ 0.00
DO NOT SKIP – THIS INFORMATION IS REQUIRED FOR SECTION A!
Did anyone listed in the Household above received SNAP benefits, formerly known as Food Stamps in 2013 or 2014?
In 2014 child support was paid by someone in the Household?
Name of Person who PAID Child Support
Yes
Yes (Complete Child Support section below)
Name of Person who RECEIVED Child Support
No
No
Name and Age of Child the Support Was For
Total Amt
$
$
PLEASE TURN TO PAGE 2 TO COMPLETE SECTION E
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.
2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
PAGE 2 OF SECTION E
I previously attended WDT
OR
I am a NEW student - the following will be provided to WDT’s Admissions Office: (Please check (X) one):
A copy of my final official high school transcript that shows the date when my diploma was awarded.
A copy of my General Educational Development (GED) transcript that includes my GED scores.
STOP –You must appear in person to complete this section and present your government issued ID (such as a driver’s license,
military ID, passport) and this form to a WDT Financial Aid staff member, who will validate the statement below at the time of submission by
maintaining a copy of your photo ID and by providing a signature and date.
Statement of Educational Purpose
I certify that I ____________________________________ am the individual signing this Statement of Educational Purpose and that the federal
Print Student’s Name
student financial assistance I may receive will be used only for educational purposes and to pay the cost of attending Western Dakota Tech for 2015–
2016.
______________________________________________________
Student’s Signature
Date
_______________________________________________________
WDT Financial Aid Staff’s Signature
Date
If you cannot appear in person at the WDT Financial Aid Office, you must provide a
copy of your government issued photo ID and have this notarized by a public notary.
Notary’s Certificate of Knowledge – Please notarize student’s signature above.
State of ____________________________ City/County of _______________________________ on ______________________(date) before
me, __________________________________ personally appeared, ________________________________ and provided to me on basis of
Notary’s Name
Printed Name of Signer
satisfactory evidence of identification __________________________ to be the above named person who signed the foregoing instrument.
Type of Government Issued Photo ID Provided
WITNESS my hand and official seal
(SEAL)
___________________________________________ ______________________________
Notary’s Signature
Date Commission Expires
If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Our signatures certify this information is correct.
Student Signature
Date
Parent Signature
Date
NOTICE: This form must be submitted to our office within 14 days of this request. If the required documentation is not received, we cannot continue processing your application for financial aid.
Processing will not resume until/unless the necessary information/documents are provided. If the 14-day time period extends to or beyond registration day, you must either pay the institutional costs from
personal funds, or request a payment plan from the Student Accounts Office.
IF YOU WERE REQUIRED TO COMPLETE SECTION E, PLEASE SIGN, DATE AND SUBMIT
BOTH PAGES OF SECTION E ONLY
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.
2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
YOU MUST HAVE ACCESS TO A PRINTER IN ORDER TO PRINT AND SUBMIT THIS FORM
Your FAFSA was selected for review in a process called verification. The law says that before awarding Federal Student Aid, we may ask you to confirm
the information you reported on your FAFSA. THIS DOCUMENT IS A FORM - PLEASE TYPE YOUR INFORMATION IN THE GRAY AREAS PROVIDED. USE THE
“TAB” KEY ON YOUR KEYBOARD TO MOVE TO THE SPACES PROVIDED – DO NOT USE THE “ENTER” KEY.
SECTION F (2 PAGES):
First Name:
Last Name:
Mailing Address:
City:
Phone:
Email:
SS#: X X X – X X State:
Zip:
HOUSEHOLD INFORMATION:
List the people in the space provided below that your parents will support between July 1, 2015 and June 30, 2016. Include yourself, your parents
(including a step parent), and your parent’s dependent children (if your parents provide more than half their support or if they would be required to give
parental information when applying for Federal Student Aid). Include the name of the college for any household member, excluding your parent(s), who
will be enrolled, at least half time in a degree, diploma, or certificate program at a postsecondary institution.
Name
Age
STUDENT:
Relationship
SELF
College Attending (if applicable)
Western Dakota Tech
Source(s) If $0 income, type below “I had no income in 2014”
IF YOU DID NOT file a 2014 federal income tax return,
mark this box, attach your W-2 forms and COMPLETE
SOURCES OF INCOME SECTION
OR
2014 Amount
$
$
NOTE: RIGHT CLICK ON THE NUMBER
TO THE LEFT, AND SELECT
UPDATE FIELD TO TOTAL THE COLUMN
$ 0.00
IF YOU FILED a 2014 federal income tax return, mark this box.
Source(s) If $0 income, type below “I had no income in 2014”
PARENTS:
2014 Amount
$
$
$
If you DID NOT file a 2014 federal income tax return.
Mark this box, attach your W-2 forms and COMPLETE
SOURCES OF INCOME SECTION
OR
IF YOU FILED a 2014 federal income tax return, mark this box.
NOTE: RIGHT CLICK ON THE NUMBER
TO THE LEFT, AND SELECT
UPDATE FIELD TO TOTAL THE COLUMN
$ 0.00
DO NOT SKIP – THIS INFORMATION IS REQUIRED FOR SECTION F!
Did anyone listed in the Household above received SNAP benefits, formerly known as Food Stamps in 2013 or 2014?
In 2014 child support was paid by someone in the Household?
Name of Person who PAID Child Support
Yes
Yes (Complete Child Support section below)
Name of Person who RECEIVED Child Support
No
No
Name and Age of Child the Support Was For
Total Amt
$
$
PLEASE TURN TO PAGE 2 TO COMPLETE SECTION F
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.
2015-16 DEPENDENT
Verification Form
800 Mickelson Dr.
Rapid City, SD 57703-4018
605-394-4034 or 800-544-8765
FAX: 605-394-2204
www.wdt.edu
PAGE 2 OF SECTION F
DO NOT LEAVE ANY OF THE FINANCIAL INFORMATION BLANK – IF THE AMOUNT IS $0, INDICATE THAT IN THE SPACE PROVIDED.
Student
2014 ADDITIONAL FINANCIAL INFORMATION
Taxable earnings from need-based employment programs such as Federal Work-Study and need-based employment portions of fellowships and
assistantships.
Parent(s)
$
$
Grant and scholarship aid reported to the IRS in the adjusted gross income. Includes AmeriCorps benefits (awards, living allowances, and interest $
accrual payments), as well as grant and scholarship portions of fellowships and assistantships.
$
Combat pay or special combat pay. Only enter the amount that was taxable and included in the adjusted gross income. Do not enter untaxed combat $
pay.
$
Earnings from work under a Cooperative Education program offered by a college.
$
$
Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings) including, but not limited to, amounts reported on the W- $
2 Form in Boxes 12a through 12d, codes D, E, F, G, H, and S. Don’t include code DD.
$
Child support you RECEIVED for all children. Do not include foster care 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 benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational WorkStudy allowances.
$
$
Other untaxed income not reported, such as worker's compensation, disability, etc. Also include the first-time homebuyer tax credit from IRS Form
$
1040 – line 67. Don’t include: student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security benefits,
Supplemental Security Income, Workforce Investment Act educational benefits, on-base military housing or a military housing allowance, combat pay,
benefits from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.
$
Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form.
XXXXXX
2014 UNTAXED INCOME
$
If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Our signatures certify this information is correct.
Student Signature
Date
Parent Signature
Date
NOTICE: This form must be submitted to our office within 14 days of this request. If the required documentation is not received, we cannot continue processing your application for financial aid.
Processing will not resume until/unless the necessary information/documents are provided. If the 14-day time period extends to or beyond registration day, you must either pay the institutional costs from
personal funds, or request a payment plan from the Student Accounts Office.
IF YOU WERE REQUIRED TO COMPLETE SECTION F, PLEASE SIGN, DATE AND SUBMIT
BOTH PAGES OF SECTION F ONLY
____________________________________________________________________________________________________________________
WDT is a public institution of higher learning that embraces quality programs, expert faculty and staff, and a commitment to academic excellence to teach the knowledge, skills, and behaviors students need to be successful.