Dependent Verification Worksheet
DEP - V6
2016-2017
Your 2016-2017 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. You and at least one parent must complete and sign
this worksheet, attach any required documents and submit the form and other required documents to the Financial Aid Office. We may ask for additional information. Should
you require further instructions; please contact our office at (505) 566-3323 or [email protected].
ANSWER EACH QUESTION BELOW AS IT APPLIES TO THE STUDENT AND THE STUDENT’S PARENT(S) WHOSE INFORMATION IS ON THE FAFSA. If any item does not apply,
enter “N/A” for Not Applicable where a response is requested, or enter 0 in an area where an amount is requested. If more space is needed, attach a separate page with the
student’s name and ID number at the top and include the additional information.
Part 1. Student Information:
First Name:
Last Name:
SJC ID:
Address:
Date of Birth:
City, State, Zip:
Phone:
SJC E-mail address:
@my.sanjuancollege.edu
Part 2. Payment to tax-deferred pension and retirement savings
List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings plans (e.g. 401(k) or 403(b) plans), including, but not limited to,
amounts reported on W-2 forms in boxes 12a through 12d with codes D,E,F,G,H, and S.
Name of person who made the payment(s)
Total amount paid between January 1 - December 31, 2015
$
$
Part 3. Child Support Received
List the actual amount of any child support received in 2015 for the children in your household.
Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid.
Name of person who received child support payment(s)
Name of child for whom child support was paid
Total amount paid between January 1
- December 31, 2015
$
Part 4. Housing, food, and other living allowances paid to members of the military, clergy, and others
Include cash payments and/or the cash value of benefits received.
Do not include the value of on-base military housing or the value of a basic military allowance for housing.
Name of recipient
Types of benefit received
Total amount paid between January 1
December 31, 2015
$
Part 5. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2015. Include Disability, Death Pension, Dependency and Indemnity Compensation (DIC), and/or
VA Educational Work-Study allowances.
Do not include federal veterans educational benefits such as: Montgomery GI Bill, Dependents Education Assistance Program, VEAP Benefits, Post-9/11 GI Bill
Total amount paid between January 1
Name of recipient
Type of Veterans non-education benefit received
- December 31, 2015
$
Part 6. Other untaxed income
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include untaxed income such as workers’ compensation, disability;
Black Lung Benefits, untaxed portions of health savings accounts from IRS Form 1040 Line 25, Railroad Retirement Benefits, etc.
Do not include any items reported or excluded in B-E above. In addition, do not include student aid, Earned Income Credit, Additional Child Tax Credit, Temporary
Assistance to Needy Families (TANF), untaxed Social Security benefits, Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits,
combat pay, benefits from flexible spending arrangement (e.g. cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.
Total amount paid between January 1
Name of recipient
Type of other untaxed income
- December 31, 2015
$
$
$
Part 7. Money received or paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g. payment of student’s bills) and not reported elsewhere on this form. If someone is paying rent, utility bills,
etc., for the student or gives cash, gift cards, etc., include the amount of that person’s contributions unless the person is the student’s parent whose information is
reported to the student’s 2016-2017 FAFSA. Amounts paid on the student’s behalf also include any distributions to the student from a 529 plan owned by someone
other than the student or the student’s parents, such as grandparents, aunts, and uncles of the student.
Total amount paid between January 1
Purpose (e.g. cash, rent, books, cell phone, auto insurance…)
Source
- December 31, 2015
$
Part 8. Additional information
So that we can fully understand the student’s family’s financial situation, please provide below information about any other resources, benefits, and other amounts
received by the student and any members of the student’s household. This may include items that were not required to be reported on the FAFSA or other forms
submitted to the financial aid office, and include such things as federal veteran’s education benefits, military housing, SNAP, TANF, etc.
Total amount paid between January 1
Name of recipient
Types of financial support
- December 31, 2015
$
$
$
$
Part 9. Family Information
List the persons in your parent’s household in the chart below. Include the following:
1. Yourself, even if you don’t live with your parents (i.e. –living in an apartment, with friends, etc.)
2. Your parent(s) in the household, including your stepparent
3. Your parents’ other children if:
a) You parents will provide more than half of the children’s support from July 1, 2016 to June 30, 2017
4. Other people if they now live with your parents and your parent(s) provide more than half of their support and will continue to provide more than
half their support from July 1, 2016 to June 30, 2017.
Also, identify the name of the college for any family member (except your parents) who will be attending college between July 1, 2016 and June 30, 2017 and will
be enrolled at least half-time (6 or more credits) in a degree or certificate program. If you need more space add a separate page.
First and Last Name*
EXAMPLE: Martha Jones
1.
Age
19
Relationship
daughter
Name of College in 2016-2017**
San Juan College
Enrolled at least ½ time
yes
SELF
(Student)
2.
3.
4.
5.
6.
7.
*Proof of financial support may be requested.
**Proof of at least half-time enrollment in 2016-2017 may be requested.
Part 10. Certifications and Signatures
If you and/or your parents did not or could not use the IRS Data Retrieval option you must provide our office with a copy of tax return transcripts. To
Request a 2015 tax return transcript go to www.irs.gov or complete form 4056 (Request for copy of Tax Reurn) or call (800) 908-9946. Tax return
transcripts can take two or more weeks to arrive. Other tax forms will NOT be accepted.
Each person signing below certifies that all of the information reported is complete and correct. The student and one parent whose information is 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.
___________________________________________________
Student Signature
___________
Date
___________________________________________________
Parent Signature
___________
Date
Return to:
San Juan College
Financial Aid Office
4601 College Blvd.
Farmington, NM 87402
FAX: 505.566.3593
EMAIL: [email protected]
Ph. 505-566-3323 Fax: 505-566-3593 E-mail: [email protected]
Address: San Juan College, Financial Aid Office, 4601 College Blvd, Farmington, NM 87402