PrattMWP Financial Aid Office
310 Genesee Street
Utica, NY 13502
Phone: (315) 797-0000 ext 2222
Fax: (315) 797-9349
Email: [email protected]
2015-2016 DEPENDENT VERIFICATION WORKSHEET
Last Name
First Name
M.I.
Social Security Number
Birth Date (month/day/year)
Gender
 Male
Permanent Mailing Address
Apt. #
City
State
Home Phone
 Female
Student Cell Phone
Zip Code
Student E-mail Address
A. Household Information
List the following:

Yourself

Your parent(s). In case of separation/divorce, only list the parent that you have lived with more in the last 12 months. If this
parent is remarried, you must also list your stepparent.

Your parents’ other children or dependents that will live in your household for the 2015-2016 academic year, and will
receive at least half of their support from your parents.
Full Name
Age
Relationship to Student
SELF
(Leave blank if not attending)
Enrolled at least half time?
(Y/N)
PrattMWP
Y
College Attending
B. Student Income Information
1.
2014 Federal Tax Return Information (required) please check one:
I used the IRS Data Retrieval Tool when completing my FAFSA application to retrieve and transfer my 2014 income tax
information.
I am attaching a copy of my IRS Tax Return Transcript (see attached instructions, do not submit a copy of your
1040, 1040A or 1040EZ Form)
I will obtain a copy of my IRS Tax Return Transcript and submit it to the school at a later date. (see attached instructions,
do not submit a copy of your 1040, 1040A or 1040EZ Form)
I was not required to file a 2014 Federal Income Tax Return. I am attaching a notarized statement indicating this.
2.
2014 W-2 Forms (required) please check one:
I was employed during 2014. I am attaching copies of my W-2 Forms received during 2014.
I was not employed and had no income earned from work in 2014.
over
C. Parent Income Information
1.
2014 Federal Tax Return Information (required) please check one:
My parent(s) used the IRS Data Retrieval Tool when completing my FAFSA application to retrieve and transfer their 2014
income tax information.
My parent(s) are attaching a copy of their IRS Tax Return Transcript (see attached instructions, do not submit a
copy of your 1040, 1040A or 1040EZ Form)
My parent(s) will obtain a copy of their IRS Tax Return Transcript and submit it to the school at a later date. (see attached
instructions, do not submit a copy of your 1040, 1040A or 1040EZ Form)
My parent(s) were not required to file a 2014 Federal Income Tax Return.
2.
2014 W-2 Forms (required) please check one:
My parent(s) were employed during 2014. They are attaching copies of all W-2 Forms received during 2014.
My parent(s) were not employed and had no income earned from work in 2014. My parents will not be attaching copies of
their W-2 Forms.
D. Untaxed Income
List below any untaxed family income for the year 2014. (Do not leave blank, enter $0 if no funds were received)
2014 Amount
Child Support Received
/yr.
Supplemental Nutrition Assistance Program (SNAP-food stamps)
/yr.
Worker’s Compensation
/yr.
Veteran’s Benefits (excludes veterans’ education benefits)
Housing, food and other living allowances paid to members of the military, clergy and others. (Don’t’ include the
value of on-base military housing or the value of a basic military allowance for housing)
In Kind Support (value of free rent, food, utilities, etc…)
/yr.
Cash Assistance
Untaxed portions of IRA distributions (IRS Form 1040-lines (15a minus 15b) or 1040A-lines (11a minus 11b). Do
not include ROLLOVERS. (If negative, enter zero)
Untaxed portions of pensions (IRS Form 1040-lines (16a minus 16b) or 1040A-lines (12a minus 12b). Do not include
ROLLOVERS. (If negative, enter zero)
Tax Exempt Interest (IRS Form 1040-line 8b or Form 1040A-line 8b)
/yr.
IRA deductions and payments (IRS Form 1040-line 28+ line 32 or 1040A-line 17.
/yr.
Payments to tax-deferred pensions and savings plans (W-2 forms boxes 12a through12d, codes D, E, F, G, H and S)
/yr.
Social Security Benefits
/yr.
Supplemental Security Income
/yr.
Health Savings Account (HSA) (IRS Form 1040 line-25)
/yr.
/yr.
/yr.
/yr.
/yr.
/yr.
E. Child Support Paid
(Only complete this section if the custodial parent paid out child support in 2014)
Name of person who paid
child support
Name of person to whom
child support was paid
Name of child for whom
support was paid
Amount of child support
paid in 2014




F. Signatures
Each person signing this form certifies that all the information reported on it is complete and accurate. Both the parent who
completed the FAFSA and the student must sign and date this form.
Student
Date
Parent
Date
