North Central State College
Verification Worksheet − V6
Financial Aid Office
2016-2017
Household resources
Student Name (print) _____________________________________ NCSC I.D. ____________________
Independent students: Provide information for yourself and spouse (if married).
Dependent students: Provide information for yourself and your parent/s. You are dependent if parent information was required
on your FAFSA. Your parent/s are those whose information was required on your FAFSA.
Do not leave any of the following sections blank. If an item does not pertain to you, enter “N/A” in the item box.
Dollar amounts are for the entire year 2015.
1.
Payments to Tax-Deferred Pension and Savings paid directly or withheld from earnings including, but not
limited to, amounts reported on W-2 forms is Boxes 12a through 12d, codes D, E, F, G, H, and S.
Name of person who made payment
Relationship to student
Amount Paid in 2015
$
$
$
2. 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.
Name of Recipient
Relationship to student
Type of Benefit Received
Amount Received
in 2015
$
$
$
3.
Veterans’ non-educational benefits such as Disability, Death Pension, or Dependency & Indemnity
Compensation (DIC) and/or VA Educational Work-Study allowances.
Name of Recipient
Relationship to student
Type of Veterans Noneducation Benefit
Amount Received
in 2015
$
$
$
4.
Other Untaxed Income such as workers’ compensation, disability, etc., untaxed portions of health savings
accounts.
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.
Name of Recipient
Relationship to student
Type of Other Untaxed
Income
Amount Received
in 2015
$
$
$
OVER
5. Money Received or Paid on the Applicant’s Behalf (e.g., bills)
Purpose (e.g., cash, rent, books)
Who provided the
benefit?
Relationship to
student
Amount Received
in 2015
$
$
$
6. 2015 Wages and Federal Income Tax Return status
□
□
No
Yes
A. Did the student work and earn wages in 2015?
Did (or will) the student file a 2015 federal income tax return? ❏ No
B. Did the student’s spouse (if married) work and earn wages in 2015?
Did (or will) the spouse file a 2015 federal income tax return? ❏ No
□
❏ Yes
No
❏ Yes
□ Yes
❏ N/A (not married)
□
□
No
Yes
C. Did the student’s parent/s (if the student is dependent) work and earn wages in 2015?
Did (or will) the parent/s file a 2015 federal income tax return? ❏ No ❏ Yes ❏ N/A (not dependent)
If “no” to all questions in A and B and C, go to the Certification Statement below.
If “yes” to any question A or B or C, complete the following:
Tax filers: contact the IRS (government tax office) at www.irs.gov and order a “Tax Return Transcript” for 2015.
Submit this to the Financial Aid Office (FAO). Go to the Certification Statement below.
Non-Tax filers:
1. Log on to the IRS web site and order a “Letter of Non-Filing” for 2015. Submit this to the FAO. Nonfiler letters are usually not available until after June 15.
2. Submit a copy of all W-2 forms received and complete the following:
Student/spouse/parent
Name of employer
Amount earned in 2015
$
$
$
$
Certification Statement
By signing here, I certify that all information being reported to qualify the student for federal student aid is true and
complete to the best of my knowledge. I understand that if I purposely give, or knowingly allow others to give, false or
misleading information to qualify the student for federal student aid, I may be fined, be sentenced to jail, or both.
Student Signature______________________________________________
Date______________________
For dependent students:
Parent Signature_________________________________________
Date______________________
Return to the NC State Financial Aid Office
143 Byron Kee Hall ✦ 2441 Kenwood Circle • Mansfield, Ohio 44906 ✦ 419-755-4899 (voice) • 419-755-4729 (fax)
[email protected] ✦ http://www.ncstatecollege.edu/cms/financial-aid.html