Office of Financial Aid
Dependent V6
Worksheet
Box 20523, 3219 College Street
Savannah, Ga 31404
[email protected]
Phone: 912-358-4162 Fax: 912-358-3167
2015-16 School Year
Your application was selected for review in a process called “Verification.” In this process, SSU will compare information
from your FAFSA with this worksheet and financial documents you will submit. This process is required by federal law and
must be completed before funds can be disbursed. By signing this form, if there are differences between your FAFSA
application and your financial documents, you authorize SSU to make electronic corrections to your FAFSA. In some
instances our office could identify errors in your data that results in an increase to your eligibility for additional aid. We will
not continue processing your application for financial aid until we have all completed and correct information.
INSTRUCTIONS
1. Collect you and your parent(s) 2014 financial documents (W-2 forms, etc.).
2. Complete all sections of this worksheet in full.
3. Submit the completed and signed Worksheet and/or any other documents requested to our office.
4. After you and your parent(s) have filed a 2014 Federal Income Tax Return with the IRS, log on to fafsa.gov and use the
“IRS Data Retrieval Tool” to automatically transfer your 2014 tax information to your FAFSA.
5. Documents must be submitted within 30 days of the initial request to be considered for all available financial aid.
A. Student Information
915
Last Name
First Name
MI
Street Address
Student ID #
Date of Birth
City
State
Zip
(Area Code) Phone Number
B. Family Information
Write the names of ALL the people in your parent(s)’ household, including:
 Yourself and your parent(s) (including stepparent) even if you don’t live with your parents.
 Your parent(s)’ other children if your parent(s) will provide more than half of their support from July 1, 2015,
through June 30, 2016, or if the other children would be required to provide parental information if they were
completing a FAFSA for 2015-16. Include children who meet either of these standards, even if they do not live with
your parent(s).
 Other people if they live with your parent(s) and your parent(s) provide more than half of their support and will
continue to provide more than half of their support through June 30, 2016.
Include the age of each family member and their relationship to the student. Also add the name of the college for any
household member (excluding parents) who will be enrolled in a degree, diploma, or certificate program at least half-time
between July 1, 2015, and June 30, 2016.
Full Name of Family Member
(EXAMPLE) Missy Jones
Age
Relationship to Student
College Attending
July 1, 2015– June 30, 2016
18
Sister
Central University
Self
Savannah State University
*If more space is required, attach a separate page.
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Tax Information
The best way to verify income is by using the IRS Data Retrieval Tool that is part of the FAFSA on the Web. If you have not
already used the tool, go to FAFSA.gov, log in to your FAFSA record, select “Make FAFSA corrections,” and navigate to the
Financial Information section of the form. If you filed electronically, the IRS will provide your information within 2 weeks; if
you filed by paper, it may take up to 8 weeks for your information to be upload via the IRS Data Retrieval Tool on the
FAFSA. If you are not eligible to use the IRS Data Retrieval Tool, you will need to request an IRS Tax Return Transcript by
calling 800-908-9946 or online at www.irs.gov/transcript. We cannot accept Federal Income Tax Returns and they will be
destroyed if received.
Non Filers
If you did not file a federal tax return, you will need to submit the Verification of Non-filing letter as well as the Wage and
Income transcript. You will need to request the IRS Verification of Non-Filing letter and the IRS Wage and Income transcript
by calling 800-908-9946 or online at www.irs.gov/transcript. The Verification of Non-filing letter will not be available
until June 16, 2015. Student may complete our Student Non-Filer Statement form to satisfy this requirement.
Individuals Who Filed an Amended IRS Income Tax Return
If you filed an amended IRS income tax return for tax year 2014, provide a signed copy of the original 2014 IRS income tax
return that was filed with the IRS or a 2014 IRS Tax Return Transcript AND a signed copy of the 2014 IRS Form 1040X,
“Amended U.S. Individual Income Tax Return,” that was filed with the IRS.
Individuals who were victims of IRS Identity Theft
If you are victim of IRS identity theft who is not able to obtain a 2014 IRS Tax Return Transcript or use the IRS Data
Retrieval Tool, you must contact the IRS at 1-800-908-4490. Upon authentication of your identity, the IRS will provide, by
U.S. Postal Service, a printout of the 2014 IRS income tax return information.
Individuals Granted a Filing Extension by the IRS
If you are required to file a 2014 IRS income tax return and have been granted a filing extension by the IRS, provide a copy of
IRS Form 4868, ‘‘Application for Automatic Extension of Time to File U.S. Individual Income Tax Return,’’ that was filed
with the IRS for tax year 2014; AND a copy of the IRS's approval of an extension beyond the automatic six-month extension
if the individual requested an additional extension of the filing time for tax year 2014; AND a copy of IRS Form W–2 for
each source of employment income received for tax year 2014 and, if self-employed, a signed statement certifying the amount
of the individual’s Adjusted Gross Income (AGI) and the U.S. income tax paid for tax year 2014.
C. Student’s Income Information – Check the box that applies
1. TAX RETURN FILERS – If you filed or will file a tax return.
 I have used, or will use the IRS Data Retrieval tool to report my income information.
 I will request a 2013 IRS Tax Return Transcript and will submit it at a later date. I understand that verification cannot be
completed until the transcripts are submitted.
2. TAX RETURN NONFILERS – If you will not file and is not required to file a 2014 tax return.
 I was not employed and had no income earned from work in 2014. I will submit the Student Non-Filer Statement form.
 I did work in 2014 but I am not required to file a tax return. I will submit the Student Non-Filer Statement form.
D. Parent’s Income Information – Check the box that applies
1. TAX RETURN FILERS – If your parent(s) filed or will file a tax return.
 The student’s parent used, or will use the IRS Data Retrieval tool to report their income information.
 The student’s parent will request a 2014 IRS Tax Return Transcript and will submit it at a later date. I understand that
verification cannot be completed until the transcripts are submitted.
2. TAX RETURN NONFILERS – If your parent(s) will not file or is not required to file a 2014 tax return. See Non-Filers
section above.
 The student’s parent(s) was not employed and had no income earned from work in 2014. I will submit the IRS
Verification of Non-Filing letter and the IRS Wage and Income transcript.
 The student’s parent(s) did work in 2014 but is not required to file a tax return. I will submit the IRS Verification of NonFiling letter and the IRS Wage and Income transcript.
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Untax Income
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. Answer each question below as it applies to the student and the student’s parent(s) whose information is
on the FAFSA.
To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in
2014, multiply that amount by the number of months in 2014 you paid or received it. If you did not pay or receive the same
amount each month in 2014, add together the amounts you paid or received each month.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
E. Payments 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
Total Payments to tax-deferred pension
and retirement savings
Annual Amount Paid in 2014
$
F. Child support received
List the actual amount of any child support received in 2014 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 Adult Who Received the
Support
Name of Child For Whom
Support Was Received
Total Amount of Child Support Received
Annual Amount of Child Support
Received in 2014
$
G. 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
Type of Benefit Received
Total Amount of Benefits Received
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Annual Amount of Benefits
Received in 2014
$
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H. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2014. 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: Post-9/11 GI Bill, Montgomery GI Bill, Dependents Education Assistance Program, VEAP
Benefits.
Name of Recipient
Type of Veterans Non-Education
Benefit
Annual Amount of Benefits
Received in 2014
$
Total Amount of Veterans Non-Education Received
I. 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 A – D 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 arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels.
Name of Recipient
Type of Other Untaxed Income
Annual Amount of Other Untaxed
Income Received in 2014
Total Amount of Veterans Non-Education Received
$
J. 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. Enter the total amount of cash support the student received in 2014. Include support from a parent whose information
was not reported on the student’s 2014–2015 FAFSA, but do not include support from a parent whose information was
reported. For example, 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 on the
student’s 2014–2015 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.
Annual Amount Received in
2014
Purpose: e.g., Cash, Rent, Books
Total Amount Received
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Source
$
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K. Housing Situation – Check the box that applies
My household lives: In pubic housing
With other family members
Military Base
With a room mate
L. Additional information
Please provide 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 veterans’ education benefits, military housing, SNAP,
TANF, etc. If more space is needed, provide a separate page with the student’s name and ID number at the top.
Name of Recipient
Annual Amount of Financial
Support Received in 2014
Type of Financial Support
Total Amount Financial Support Received
$
M. Comments
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
_______________________________________________________________
N. Sign this Worksheet
Each person signing this form certifies that all the information reported on it is complete and correct. If a correction is needed,
you authorize Savannah State University to make the correction. The student and one parent must sign and date.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced
to jail, or both.
Student’s
Signature
Date
Parent
Signature
Date
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