FACDVF
Financial Aid and Scholarships
Dependent Verification Worksheet
2016-2017
Page 1 of 2
Your FAFSA application was selected for review by the Department of Education in a process called Verification. What you should do:
1.
Complete this worksheet and submit to Financial Aid and Scholarships.
2.
Attach your and your parent(s) 2015 Tax Return Transcripts and separate W-2 forms. If you and your parent(s) are unable to obtain the
tax return transcript then you and your parent(s) may provide a signed copy of the applicable 2015 1040, 1040A or 1040EZ form(s) and
separate W-2 forms. Please note our office is only accepting copies of the 1040, 1040A or 1040EZ form(s) for a limited time per
updated guidance from the Department of Education and this policy is subject to change.
3.
Reference your WebAdvisor for any other required documentation.
Allow two to three weeks for processing. Please note the processing time of verification may be longer during peak periods.
SECTION A: STUDENT INFORMATION_______________________________________________________________
Last Name _____________________________________________ First Name _____________________________________ M.I. _____
SSN/ID ______________________ Date of Birth __________________ Student Phone Number (_____) _________________________
Address (include apt. no.) _________________________________________________________City ____________________________
State __________________________ ZIP Code ________________ Email Address __________________________________________
SECTION B: FAMILY INFORMATION______________________________________________________ __________
List the people in your parents’ household, including:




Yourself (even if you don’t live with your parents), and
Your parent(s), (including step-parent, if applicable). Do not include a parent not living in the home due to divorce/separation.
Your parents’ other children, even if they don’t live with your parent(s), if (a) your parents will provide more than half of their
support, or (b) the children would be required to provide parental information when applying for Federal Student Aid.
Other family members if they live with your parents and your parents provide more than half of their support and will continue to
provide more than half of their support from July 1, 2016, through June 30, 2017.
***Support includes money, gifts, loans, housing, food, clothes, car, medical and dental care, payment of college costs, etc.***
Full Name (Legal Name)
Age
Relationship
If additional space is needed, please attach a separate page that includes the student’s name and SSN/ID number at the top.
List the full name(s), age(s) and college(s) of any family member in the household who will be attending college at least halftime between
July 1, 2016, and June 30, 2017, and who will be enrolled in a degree or certificate program. Do not include parent(s) in table below.
Full Name
Age
College (attending 2016/2017) – no abbreviations
If additional space is needed, please attach a separate page that includes the student’s name and SSN/ID number at the top.
Continued on back
Please return completed form to: Coastal Carolina University / Financial Aid and Scholarships / P.O. Box 261954 / Conway, SC 29528-6054
Faxes are accepted: 843-349-2347.
Student Name ________________________________________________________ SSN/ID ___________________________________
FACDVF
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SECTION C: NON-TAX FILER INFORMATION (if applicable)____________________________________________
□
I (the student) am not required to file a 2015 federal income tax return to the IRS.
NOTE: If a federal tax return is not filed but you earned income from working in 2015, then submit your W-2(s).
□
My parent(s) are not required to file a 2015 federal income tax return to the IRS.
NOTE: If a federal tax return is not filed but your parent(s) earned income from working in 2015, then submit their W-2(s).
SECTION D: STUDENT’S AND PARENTS’ UNTAXED INCOME INFORMATION_______ ___________________
****DO NOT LEAVE ANY BLANKS. Enter “0” or “N/A” if not applicable. ****
Source of Untaxed Income
Student (2015 Total)
Parent (2015 Total)
Payments to tax-deferred pension, savings plans, non-taxable sick pay and
employer contributions to your health savings account. Review 2015 W-2 forms
in Boxes 12a through 12d, codes D, E, F, G, H, J, S and W.
Child support received for all dependent children in 2015.
Housing, food and other living allowances paid to members of the military,
clergy and others (including cash payments and cash value of benefits) in 2015.
DO NOT INCLUDE the value of on-base military housing or the value of basic
military allowance for housing.
Veteran’s non-education benefits in 2015 such as disability, death pension, or
dependency and indemnity compensation (DIC) and/or VA educational workstudy allowances.
Cash support (money paid on your behalf) in 2015.
Other untaxed income or benefits not reported elsewhere on this form in 2015,
such as worker’s compensation, disability, etc. DO NOT INCLUDE social
security benefits, student aid or welfare payments.
***If your parents’ total income (taxed and untaxed) is less than $7,500.00, then please have them submit a signed statement
clarifying how the household was supported in 2015.***
SECTION E: ADDITIONAL FINANCIAL INFORMATION____________________________ ___________________
1.
Did you, your parents or anyone in your parents’ household receive food stamps and/or benefits from the Supplemental Nutrition
Assistance Program (SNAP) in 2014 and/or 2015? Check the applicable box below:
 Yes
2.
No
Did you and/or your parents PAY child support in 2015? Do not include child support paid for children who live in your
parents’ household that they support. Check the applicable box below:
 Yes (complete the table below)
Name of Person who Paid Child
Support in 2015
No
Name of Person who Received
Child Support in 2015
Name of Child for Whom
Support was Paid in 2015
Amount Paid in
2015
$
$
If additional space is needed, please attach a separate page that includes the student’s name and SSN/ID number at the top.
SECTION F: CERTIFICATION AND SIGNATURES_____________________________________________________
By signing this worksheet, we certify that all information reported is complete and accurate. (Typed signatures will not be accepted.)
_________________________________
___________________________ ____________
Student Signature
Student Printed Name
Date
_________________________________
___________________________ ____________
Parent Signature
Parent Printed Name
Date
WARNING: If you purposely
give false or misleading
information on this
worksheet, you may be fined,
sentenced to jail or both.
Please return completed form to: Coastal Carolina University / Financial Aid and Scholarships / P.O. Box 261954 / Conway, SC 29528-6054
Faxes are accepted: 843-349-2347.