To submit the completed form: In person: Office of Financial Aid, BurginDossett – Room 105; Mail: Office of Financial Aid, P.O. 70722, Johnson
City, TN 37614; Fax: (423) 439‐5855; Email: [email protected]
2016-2017 VERIFICATION - TAX FILING EXTENSION INSTRUCTIONS
Approximately 30% of all FAFSA applications are randomly selected for the Verification process. As part of this process,
students selected must verify income information before financial aid can be awarded. Students selected for
Verification and who are only interested in receiving the Hope Scholarship ($4,000) can complete the Verification OptOut Form. Verification can still be completed at a later date by student request. Students will need to contact our
office if they wish to use the Opt-Out Form. To verify income, students/parents (if dependent) must verify their income
by submitting the IRS Tax Return Transcript obtained from the IRS or by correcting the FAFSA and utilizing the IRS Data
Retrieval Tool to import tax information from the IRS into the FAFSA. Even if the federal tax return has not been filed,
income information must be verified. Instructions for tax filers filing an extension are detailed below.
I.
Tentative Award Process
ETSU has implemented a Verification process to award aid tentatively based upon estimated income information. Submit the
following seven items.
1. Submit the 2016-2017 Verification: Tax Filing Extension form.
a. Check each item (Required Information Section) being submitted with this form. It is best to submit all
documents at the same time.
b. Student must initial all three statements in the Agreement Section.
2. Submit a copy of IRS Form 4868, Application of Automatic Extension of Time to File a U.S. Individual Tax Return.
3. Submit copies of all W-2s and 1099s for each source of income in 2015 for the student, spouse or parent filing an
extension.
4. Submit either the 2016-2017 Verification Worksheet/Dependent Student form or the 2016-2017 Verification
Worksheet/Independent Student form.
5. Submit the 2016-2017 Verification of Estimated 2015 Taxable and Non-taxable income form.
c. DO NOT leave any section or items blank. Place a zero in items that DO NOT apply.
d. Use the 2014 federal tax return as a guide to complete this form, replacing the figures with estimated 2015
figures.
6. Submit a signed copy of the 2014 federal tax return, including all Schedules, W2s and 1099s.
7. Submit the 2016-2017 Asset Verification Worksheet.
The Financial Aid Office will review the information submitted and make any necessary corrections. Aid will be awarded based
upon the Financial Aid Office’s normal awarding schedule. A hold will be placed on the following semester’s aid until
verification of the actual 2015 tax information has been submitted.
II.
Finalized Verification- Required
Submit a copy of the 2015 IRS Tax Return Transcript and all schedules as soon as the return is filed. The Financial Aid Office
will review and compare the FAFSA information with the actual 2015 tax return transcript and make any necessary corrections.
If the eligibility of the original, tentative award changes, the tentative awards will be adjusted accordingly. The student is
responsible to repay any funds he/she is no longer eligible to receive. Failure to submit the IRS tax return transcript will result
in the cancellation of tentative aid already paid and the cancellation of pending disbursements. The IRS tax return transcript
should be submitted no later than November 15th to allow sufficient processing time to prevent delay of future
disbursements by the fee payment deadline.
Student and/or parent can also use the IRS Data Transfer tool to correct the FAFSA after filing their tax returns by the
extension deadline which is October 15.
To submit the completed form: In person: Office of Financial Aid, BurginDossett – Room 105; Mail: Office of Financial Aid, P.O. 70722, Johnson
City, TN 37614; Fax: (423) 439‐5855; Email: [email protected]
2016-2017 Verification - Tax Filing Extension Form [TAXEXT]
Last Name:
ETSU Student ID: E
First Name:
ETSU EMAIL:
MI:
@goldmail.etsu.edu
Your FAFSA was selected for the Verification process by the Central Processing System. As part of this process, specific items included on the
FAFSA must be verified. One of the items the Financial Aid Office is required to verify is the information reported from the federal income
tax return. By completing this form, you are requesting that financial aid to be initially awarded based upon estimated federal tax
information. The information you submit must document that the estimated income reported on the FAFSA is realistic. If not, the Financial
Aid Office reserves the right to make corrections to the estimated income. An example would be overstating taxes paid, which impacts the
EFC.
Incomplete information will delay the processing of financial aid.
REQUIRED INFORMATION
Initial by each item that is being submitted with this form
I, the student (spouse) have filed for an extension
I, the parent have filed for an extension
Submitting the required signed copy of the 2014 federal tax return, including ALL schedules, W-2s and
1099s. T h e 2014 federal tax return will be used to review estimated 2015 information reported on the
FAFSA and to identify potential untaxed income, assets and investments that are required to be
reported on the 2016-2017 FAFSA. The tax filer who is filing an extension must submit the 2014
federal tax return, Schedules, and W-2s or the request is considered to be incomplete.
Submitting a copy of the IRS Form 4868, Application for Automatic Extension of Time to File U.S.
Individual Tax Return with this form or the IRS's approval of an extension beyond the automatic sixmonth extension.
Submitting the requested 2016-2017 Verification Worksheet (Dependent or Independent based upon
the FAFSA dependency status)
Submitting the 2016-2017 Verification of Estimated 2015 Taxable and Non-taxable Income form.
Submitting a copy of ALL W-2s and/or 1099s for each source of income in 2015 for the student, spouse
or parent filing an extension.
I (student/spouse/parent) am submitting the 2016-2017 Asset Verification form. (Circle one)
AGREEMENT - THE STUDENT MUST READ AND INITIAL EACH STATEMENT
After the 2015 tax return is filed, I agree to submit a copy of all pages (all Schedules) of the 2015 IRS Tax
Return Transcript to the ETSU Office of Financial Aid or transfer income from the IRS to my FAFSA using
the IRS Data Transfer Tool. Based on the information submitted, corrections to the FAFSA may be
required. I understand that corrections may result in increased or decreased eligibility.
I agree to repay any funds that I am no longer eligible to receive as a result of required corrections to
the FAFSA or failure to submit the 2015 IRS Tax Return Transcript or use Data Retrieval Tool.
I understand that a hold will be placed on future disbursements during the 2016-2017 academic year
until the FAFSA has been correctly updated with actual 2015 federal income tax information. Failure to
comply will result in the cancellation of aid disbursed based on estimated income.
Signature of both student and parent (if dependent) is required. I certify that the above information is correct. If I purposely
give false or misleading information, I may be fined $20,000, sent to prison, or both.
Student Signature
Date
Parent Signature
Date
To submit the completed form: In person: Office of Financial Aid, BurginDossett – Room 105; Mail: Office of Financial Aid, P.O. 70722, Johnson
City, TN 37614; Fax: (423) 439‐5855; Email: [email protected]
2016-2017 Verification of Estimated 2015 Taxable and Non-taxable Income
Last Name:
ETSU Student ID: E
First Name:
ETSU EMAIL:
MI:
@goldmail.etsu.edu
This form must be submitted with the 2016-2017 Verification: Tax Filing Extension form to validate estimated 2015 income
reported on the FAFSA for the student and/or parent who filed a tax extension (IRS Form 4868).
The information below is application to the
student (spouse) or
parent, who filed a tax extension (Check one)
1. 2015 Income: (IRS Form 1040 information)
Wages, salaries, tips, etc. (total of all applicable W-2s):
Taxable interest (Submit Form 1099-INT):
Tax exempt interest - List amount here $
Ordinary dividends:
Qualified dividends - List amount here $
Taxable refunds, credits, or offsets of state and local income taxes:
Alimony received:
Business income or (loss):
Capital gain or (loss):
Other gains or (losses):
IRS distributions - Total amount of IRA distribution: $
Pensions and annuities - Total amount of pensions/annuities: $
Rental real estate, royalties, partnerships, S corporations, trusts, etc.:
Farm Income or (loss):
Unemployment compensation (Submit Form 1099-G):
Social security benefits - Total amount: $
Other income - List type and amount
Total Income
Taxable amount:
Taxable amount:
Taxable amount:
$
$
XXXXXXXXXXXX
$
XXXXXXXXXXXX
$
$
$
$
$
$
$
$
$
$
$
$
$
2. 2015 Adjusted Gross Income (IRS Form 1040 information)
Educator expenses:
Certain business expenses of reservists, performing arts and fee-basis government officials:
Health savings account deduction:
Moving expenses:
Deductible part of self-employment tax:
Self-employment SEP, SIMPLE, and qualified plans:
Self-employment health insurance deduction:
Penalty on early withdrawal of savings
Alimony paid:
IRS deduction:
Student loan interest deduction:
Tuition and fees:
Domestic production activities deduction:
Total of Column 2:
Adjusted Gross Income (Total Income in Section 1 minus Total of Column 2):
$
$
$
$
$
$
$
$
$
$
$
$
$
$
$XXXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
$
To submit the completed form: In person: Office of Financial Aid, BurginDossett – Room 105; Mail: Office of Financial Aid, P.O. 70722, Johnson
City, TN 37614; Fax: (423) 439‐5855; Email: [email protected]
3. 2015 Tax and Credits (IRS 1040 Form information)
Adjusted Gross Income (AGI) from Section 2:
Itemized deductions (estimated amount to be reported from Schedule A):
Exemptions (Multiply $3,950 by # of exemptions to be claimed on tax return):
Estimated Taxable Income: (AGI minus deductions and exemption total):
Foreign tax credit
Credit for child and dependent care expenses:
Education credits:
Retirement savings contributions credit:
Child tax credit:
Residential energy credits:
Other credits:
Total Credits:
Adjusted Gross Income minus Total Credits:
Total of Column 2:
Taxable Income (Total Income in Section 1 minus Total of Column 2):
XXXXXXXXXX
$
$
XXXXXXXXXX
$
$
$
$
$
$
$
$
XXXXXXXXXX
$
$XXXXXXXX
4. 2015 Untaxed Income
Child support received for ALL children included in the household on the FAFSA:
Housing, food and other living allowances paid to members of the military, clergy and others
(including cash payments and cash value of benefits0> Don’t include the value of on-base
military housing or the value of basic military allowance for housing.
Veteran's non-educational benefits, such as Disability Death Pension, or Dependency and
Indemnity Compensation and/or VA Educational Work-Study allowances:
Other untaxed income such as worker's compensation, disability, first-time homebuyer tax
credit:
IMPORTANT:
$
$
$
$
DO NOT leave any section blank. Place a zero in the item(s) that DO NOT apply.
Incomplete forms will delay the processing of Title IV aid.
5. Certification
Signature of both student and parent (if dependent) is required. I certify that the above information is correct.
If I purposely give false or misleading information, I may be fined $20,000, sent to prison, or both.
Student Signature/Date
Parent Signature/Date
$
XXXXXXX
XXXXXXX
$
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
XXXXXXX
$
XXXXXXX
$
To submit the completed form: In person: Office of Financial Aid, BurginDossett – Room 105; Mail: Office of Financial Aid, P.O. 70722, Johnson
City, TN 37614; Fax: (423) 439‐5855; Email: [email protected]
2016-2017 Asset Verification Worksheet
Last Name:
ETSU Student ID: E
First Name:
ETSU EMAIL:
MI:
@goldmail.etsu.edu
This form must be submitted with the 2016-2017 Verification: Tax Filing Extension form. It may also be required to resolve
conflicting information discovered through the verification process. Fully complete the section below. DO NOT leave any
section blank. Place a zero in the item(s) that DO NOT apply. Incomplete forms will delay the processing of Title IV aid.
Parental information is only required for dependent (as defined by the FAFSA) students.
Parent
Cash, savings and checking accounts. Enter your total balance as of the
day the original FAFSA was signed.
Real estate value: List the value of rental property, land, second or
summer homes. DO NOT include the home you live in.
Real estate debt: Amount owed on investment real estate. DO
NOT include the amount you owe on the home you live in.
Investments: Trust funds, UGMA and UTMA accounts (exclude if
custodian and not owner of account), money market funds, mutual
funds, certificates of deposit, stocks, stock options, bonds, other
securities, commodities, installment and land contracts (including
mortgages held).
$
$
$
$
$
$
$
$
Qualified educational benefits or education savings accounts:
Coverdell savings accounts, 529 college savings plans and the refund
value of 529 prepaid tuition plans.
$
Business Value: Include the market value of land, buildings, machinery, $
equipment, inventory, etc. (Value minus debt applicable to business
only). Name of business:
DO NOT include value of small business if your family owns and controls
more than 50% AND the business has 100 or fewer employees.
Farm value: Include the market value of land, buildings, machinery,
equipment, inventory (value minus debt applicable to farm only). DO
NOT include farm value, if the farm is the principal place of residence
for the student and family (spouse, if applicable and parents of
dependent student) AND the student (or parents of a dependent
student) materially participated in the farming operation.
Small business value:
100 or fewer employees)
Name of business:
Student
$
$
$
$
$
$
Percentage of family:
Number of employees:
Signature of both student and parent (if dependent) is required. I certify that the above information is correct. If I
purposely give false or misleading information, I may be fined $20,000, sent to prison, or both.
Student Signature/Date
Accessibility Checked 10/30/14
Parent Signature/Date