3333 Regis Boulevard, A-8
Denver, Colorado 80221-1099
303-458-4126 / 1-800-568-8932
FAX: 303-964-5449
www.regis.edu
Enrollment Services
Financial Aid
2012-2013 Institutional Verification Form – Dependent or Independent
Student’s Name
Phone
Student ID
Regis E-Mail
SECTION A: HOUSEHOLD SIZE
If dependent, list the people in your parents’ household who will receive more than half of their financial support from your parents
between July 1, 2012, and June 30, 2013. Include yourself, your parent(s) (including stepparent), your parents’ other children, and other
people if they now live with your parent(s) and receive more than half their financial support from your parents. Include the name of the
college for any household member, excluding your parents, who will be attending college at least half-time between July 1, 2012, and
June 30, 2013, and will be enrolled in a degree, diploma, or certificate program.
If independent, list the people in your household who will receive more than half of their financial support from you (and your spouse, if
married) between July 1, 2012, and June 30, 2013. Include yourself, your spouse, your children, and others if they now live with you, and
you provide more than half of their support. Write in the name of the college for any household member attending college at least half-time
between July 1, 2012, and June 30, 2013, and enrolled in a degree, diploma, or certificate program.
Name
1.
Age
Relationship to Student
Self
College/University (if applicable)
Regis University
2.
3.
4.
5.
6.
7.
 Check here if there are more than seven family members and attach a list of these people to this form.
FOOD STAMPS/SUPPLEMENTAL NUTRITION ASSURANCE PROGRAM (SNAP) – In 2010 or 2011, did you, your parents, or anyone in
your/your parents’ household receive food stamps/SNAP benefits? Yes____No____
SECTION B: NON-FILERS
Student (and Spouse, if applicable) This section must be completed if you are not filing a 2011 Federal Tax Return.
 I/We will not file and are not required to file a 2011 Federal Income Tax return.
Student’s Parents Complete this section if your parents provided information on your FAFSA and will not file a 2011 Federal Tax Return.
 My parents will not file and are not required to file a 2011 Federal Income Tax return.
INCOME EARNED FROM WORK - Complete if you are a student, spouse or parent who is not filing a 2011 Federal Income Tax
return yet has earnings from work in 2011. If both student and parent(s) are non-filers, attach another sheet with the information
below.
All non-filers should attach W-2 form(s) or other earnings statements.
Name of Non-Filer_____________________________ Employer______________________________ 2011 Earnings____________
Name of Non-Filer_____________________________ Employer______________________________ 2011 Earnings____________
Name of Non-Filer_____________________________ Employer______________________________ 2011 Earnings____________
FA 12 IVF
Revised March 30, 2012
Page 2: Institutional Verification Form – Complete ALL blanks even if zero. If not applicable, report -0- or N/A.
SECTION C: ADDITIONAL FINANCIAL INFORMATION – As reported on question 43 and 91 of the 2012-2013 FAFSA
Additional Financial Information – 2011 Total Amount
Complete ALL blanks even if zero. If not applicable, report -0- or N/A.
Parents or
Spouse
Student
Taxable earnings from need-based employment programs, such as Federal Work-Study and needbased employment portions of fellowships and assistantships.
$
$
Child support paid because of divorce or separation or as a result of a legal requirement. Don’t include
support for children in your (or your parents’) household (Section A).
$
$
Names of children for whom child support was paid:
Name of the person to whom child support was paid:
SECTION D: UNTAXED INCOME – As reported on questions 44 and 92 of the 2012-2013 FAFSA
Untaxed Income – 2011 Total Amount
Complete ALL blanks even if zero. If not applicable, report -0- or N/A.
Parents or
Spouse
Student
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. Include untaxed portions of 401K and 403B plans.
$
$
Child support received annually for all children. Don’t include foster care or adoption payments.
$
$
Housing, food, and other living allowances paid to members of 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.
$
$
Veteran’s non-education benefits such as disability, death pension, or dependency and indemnity
compensation (DIC) and/or VA educational work-study allowances.
$
$
$
$
Other untaxed income and benefits. List sources:
SECTION F: BUSINESS – Complete if you or your parents owned a business or were self-employed in 2011. If not, enter “N/A”.
Name of Business Owner __________________________________________ Number of full-time employees _______________
SECTION G: INVESTMENTS – Complete if you/spouse, or your parents have any current investments. If not, enter “N/A.”
Type of Investment
Parent(s) – Current Net Worth of
Investment (market value minus debt)
Real Estate (not including the home you live in)
Stocks Owned
Current balance of Cash + Checking + Savings
Other Investments
$
$
$
$
Student/Spouse - Current Net
Worth of Investment
(market value minus debt)
$
$
$
$
(Other Investments may include: trust funds; money market funds; mutual funds; certificates of deposit; stocks; bonds; other securities,
Coverdell savings accounts, college savings plans, installment and land sale contracts, commodities, etc.)
Did you have an IRA distribution in 2011 as a result of a ROLLOVER (transfer of funds
from one IRA to another)?
Did you receive any pension and/or annuity payments in 2011 as a result of a
ROLLOVER (transfer of funds from one IRA to another)?
Parent
Student/Spouse
Yes____No____
Yes____No____
Yes____No____
Yes____No____
I/We certify that the information on this form is complete and correct.
___________________________________________________
Student’s Signature
Date
PRINT
________________________________________________
Parent’s Signature (if student is dependent)
Date
Return this form to: Financial Aid, Regis University, 3333 Regis Boulevard A-8, Denver, CO 80221. FAX 303-964-5449.
FA 12 IVF
Revised March 30, 2012