2016-2107 Verification of Child Support Paid
A. STUDENT INFORMATION (For institutional identification purposes) ID:_________________
_______________________________________________________
(Last Name)
(First Name)
__________________
(M.I)
(Telephone Number)
______________________________________________________________________________
(Current Address)
(City)
(State)
(Zip Code)
INSTRUCTIONS: You indicated on the FAFSA that someone in your household paid out child
support in 2015. Please complete section B below to verify the information.
Your financial aid cannot be processed until this information is received.
B. Child support paid information – All lines MUST be complete. (If more than one child,
please separate with a comma)
Name(s) & age(s) of children for whom support was paid:
_____________________________________________________________________________________
_____________________________________________________________________________________
Name of person to whom child support was paid: ____________________________________________
Name of person who paid the child support (Person who should sign below): ______________________
(Please print)
Amount of child support paid for calendar year 2015: _________________________________________
Payer’s relation to student (Circle one):
Self
Spouse
Mother
Father
C. Sign this Worksheet
By signing this worksheet, I certify that all of the information reported on this worksheet is
complete and correct.
__________________________________________
(Payer Signature)
__________________
(Date)
Warning: If you purposely give false or misleading information on the worksheet, you may be fined, sentenced to jail, or both.
Forms can be returned to:
Valley City State University Financial Aid Office
101 College St SW, Valley City ND 58072
Fax: 701-845-7545 Phone: 1-800-532-8641 or 701-845-7542
E-mail: [email protected]