2016-17 V6 Household Resources
Your FAFSA was selected for a process called verification. Federal Regulations require we ask you to confirm
information you reported on your FAFSA before financial aid may be awarded. To verify that you provided correct
information, we will compare your FAFSA with the information on this institutional verification document and with any
other required documents. If there are differences, your FAFSA information may need to be corrected. Forms may be
faxed, mailed, emailed (scanned with all required signatures), or delivered in person. Your MyUDC account
(my.udc.edu) will be our primary means of contacting you so please monitor your account regularly.
PLEASE READ AND COMPLETE ALL SECTIONS)
A. Student Information (please print)
____________________________________________
Student’s Last Name
First Name
M.I.
N00-________________________
UDC Student ID#
_____________________________________________
____________________________
Student’s Email Address
Daytime Phone Number
B. Dependency Status
If you can check ANY of the following boxes, you are considered an INDEPENDENT student and will not
have to provide parental information or signature.
If you check NONE of the following boxes, you are considered a DEPENDENT student and will be required to
provide parental information and signature.
I was born before
January 1, 1993
I am married
I am serving on active duty in
the U.S. Armed Forces
I am a veteran of the U.S.
Armed Forces
Since I turned age 13, both of
my parents were deceased
I was in foster care since
turning age 13
I was a dependent or ward of
the court since turning age 13
I am currently or I was an
emancipated minor
I will be working on a master’s or doctorate
program (e.g., MA, MBA, MD, JD, PhD, EdD,
graduate certificate)
I now have or will have children for whom I will
provide more than half of their support
between July 1, 2016 and June 30, 2017
I have dependents (other than children or my
spouse) who live with me and I provide more
than half of their support
I am currently or
I am homeless or I am
I was in legal guardianship at risk of being homeless
Note: Inaccurate or incomplete information will result in the student having to resubmit this application and further
delay the processing of you aid.
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2016-17 V6 Household Resources
C. Family Information
Independent Student
Dependent Student
Independent S tudent household include:
Dependent S tudent household include:
- The student
- The student’s spouse, if married and dependent
children, even if they do not live with you, and
- Other people if they now live with you and you
provide more than half of their support from July 1,
2016 to June 30, 2017
- The student
- The student’s parent(s), including stepparent, that you
last lived with even if you don’t live with them now.
- Other people if they now live in your parent’s household
and provide more than half of their support from July 1,
2016 to June 30, 2017 (ex: siblings, etc.)
Include the names and information for the persons in your household, according to your dependency status.
Note: If more space is needed, attach a separate page with the requested information below. Include your name and ID number.
Age
Relationship
College
Full Name
Self
Attending a college or
university at least half
Time
(Please Circle)
UDC
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
D. Supplemental Nutritional Assistance Program (SNAP/ Food Stamps) Benefits (Please Check One)
Yes __ No __ One of the persons listed in Section C of this worksheet received SNAP benefits (formerly known as food
stamps) during the 2014 or 2015 calendar years. If asked by the student’s school, I will provide documentation of
the receipt of SNAP benefits during 2014and/or 2015.
E. Payments to Tax Deferred Pension and Retirement Savings (Please Check One)
Yes __ No __ Either I, or my spouse (if married), or my parent(s) (if dependent) made payments to tax-deferred pension and
Retirement savings in 2015. 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. Attach 2015 W2 Form(s).
Name of Person Who Made the Payment in 2015
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Total Amount Paid in 2015
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2016-17 V6 Household Resources
F. Child Support Paid (Please Check One)
Yes __ No _
Either I, or my spouse (if married), or my parent(s) (if dependent) who is listed in Section C of this worksheet, paid
child support in 2015. If yes, please enter the requested information below. Also, if more spaces are needed, please
attach a sheet with the requested information to this worksheet.
Name of Student/Spouse or
Parent/ Step Parent Whom
Paid Child Support
Name of Person to Whom
Child Support was Paid
Name of Child for Whom
Support Was Paid
Age of Child
for Whom
Support Was
Paid
Total Amount of
Child Support Paid
in 2015
Note: If we have reason to believe that the information regarding child support paid is inaccurate, we may require additional
documentation, such as:


A signed statement from the individual receiving the child support certifying the amount of child support received.
Copies of the child support payment checks, money order receipts, or similar records of electronic payments having been made.
G. Child Support Received (Please Check One)
Yes
No
Either I, or my spouse (if married), or my parent(s) (if dependent) received child support for someone in our
household in 2015. List the actual amount of any child support received in 2015 for the children in your household.
Do not include foster care payments, adoptions payments, or any amount that was court ordered but not actually paid.
If you need more space, attach a separate page that includes the student’s name and Student ID Number at the top.
Name of Person to Who Received Child
Support
Name of Child for Whom Support Was
Received
Total Amount of Child
Support Received in 2015
Chris Smith (example)
Terry Jones
$6000
H. Housing, Food, and Other Living Expenses Paid to Members of the Military, Clergy, and Others
(Please Check One)
Yes
No
Either I, or my spouse (if married), or my parent(s) (if dependent) receive housing, food, or other living expenses paid
to members of the military, clergy, or others in 2015. 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
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Total Amount Received in
2015
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2016-17 V6 Household Resources
I. Veterans Non-Educational Benefits (Please Check One)
Yes
No
Either I, or my spouse (if married), or my parent(s) (if dependent) receive any veterans non-education benefits in
2015. List the total amount of veterans non-education benefits received in 2015. 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: Montgomery GI Bill, Dependents Education Assistance Pro gram,
VEAP Benefits, Post 9/11 GI Bill.
Name of Recipient
Type of Veteran Non-Educational Benefit
Total Amount of Benefit
Received in 2015
J. Other Untaxed Income (Please Check One)
Yes
No
For yourself, spouse (if married), and parent(s) (if dependent): 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 elsewhere on this form. 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) education
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
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Total Amount Received in 2015
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2016-17 V6 Household Resources
K. Income Information
Check the box below that best describes the status of your 2015 Federal Tax Return. If you filed taxes, we
highly recommend that you utilize the IRS Data Retrieval Tool (DRT). If you cannot use the DRT then
you will need to provide a copy of your 2015 Federal Tax Return Transcript.
2015 Tax Filers
S tudent and/or S pouse
Parent(s) and/or S tepparent
Check here if you have completed the 2015 Federal Tax Return and used
the IRS DRT on your FAFSA.
Check here if you did not/could not use the DRT and are submitting a Federal
Tax Return Transcript (attach transcripts).
Request
Method
Online
(On Demand)
Online
(By Mail)
Telephone
Paper Request
Form
4506T-EZ or
4506-T
How?
Processing Days
www.irs.gov/transcript
Same Day
*Make sure to request the IRS Tax Return
Transcript not the IRS Tax Account Transcript
www.irs.gov/transcript
5-10 Days
*Make sure to request the IRS Tax Return
Transcript not the IRS Tax Account Transcript
(800) 908-9946
www.irs.gov/pub/irs-pdf/f4506tez.pdf
5-10 Days
10 Days
Check here if you have completed a 2015 Federal Tax Return as Married Filing
Separately (will need to attach both spouses’ tax return transcripts).
Check here if you filed an Amended 2015 Federal Tax Return (Form 1040X).
You will need to attach both Form 1040X and your tax return transcript.
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K. Income Information (Continued )
Not Filing Taxes
Student and/or Spouse
Parent(s) and/ or Stepparent
Check here if you had income will not file and were not required to file a 2015 Federal Tax
Return. Attach copies of all of your 2015 W2 Form(s).
Check here if you had no income in 2015. See additional instructions below.
Please provide the below information about any additional financial resources received by
the student and any members of the student’s household. If you respond no to all of the
financial support items below, you must provide a statement in the comment section.
Source of
Financial
Support
Please
Circle One
TANF
WIC
Social Security
(SSI/SSDI)
Subsidized
Housing
Cash Support*
Y or N
Y or N
Y or N
In-Kind*
Support
Y or N
Other:
_____________
Y or N
Name of Recipient
Total
Amount of
Support
Received in
2015
Y or N
Y or N
* In kind support means that you used someone else’s resources as a means of living—i.e. you
lived at your grandmother’s house and used her utilities. Cash support received or paid on your
behalf means that you had bills in your name but someone else either gave you the mon ey to pay
those bills or someone else paid them on your behalf.
Comments:
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
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L. Certifications and Signatures
WARNING: If you purposely give false
information on this worksheet, you may be
Each person signing below certifies that all of the
information reported is complete and correct.
The student and one parent whose information was
reported on the FAFSA must sign and date.
fined, be sentenced to jail, or both.
________________________________________
Student Signature
________________________
Date
________________________________________
Parent Signature (required if dependent)
________________________
Date
*Parent signature required if you answered no to all of the dependency status questions in Section B of this form.
Please submit to the UDC Financial Aid Office
In Person
Flagship Campus, Building 39, A-133 or at Community College, 801 North Capitol, 3rd Floor, Room 305
Fax: 202-274-6060, EMAIL: [email protected]
Mailing Address
UDC-Office of Financial Aid
4200 Connecticut Ave. NW
Bldg. 39, Suite A-133
Washington, DC 20008
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