VWI6O
S
Student ID Number
2016-17 Verification Worksheet for Independent Student-Form 6
Printed Name: _________________________________
Phone Number:____________________________________
Entire form must be completed in black or blue ink.
Student Information
List the people in your household, including:
• Yourself (as the ‘Student’), and your spouse if you were married at the time the FAFSA was completed and;
• Your dependent children, if you will provide more than half of their support * from July 1, 2016 through June 30, 2017, even if
they do not live with you, and;
• Other people if they live with you and you 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/dental care, college tuition, etc.
The Name of the College Attending from July 1, 2016
Full Name
Age
Relationship to
to June 30, 2017. Must attend at least ½ time & be
Student
enrolled in an eligible degree and/or certificate.
Self
*Use a separate sheet/page to list additional members in the household*
Student/Spouse Income Information
If you and/or your spouse filed a Federal Income Tax Return, you must either submit to the Financial Aid Office a 2015 Federal Tax Return
Transcript(s) or a signed paper copy of the 2015 IRS tax return that was used by the tax filer for submission to the IRS.
To obtain an IRS Tax Return Transcript, you may go to http://www.irs.gov/Individuals/Order-a-Transcript and click on “Get a Transcript by
MAIL” or call 1-800-908-9946. Be sure to order the IRS Tax “Return” Transcript.
For Tax Filers
Check the boxes that apply to you and/or your spouse:
□ Attached Tax Return Transcript

□ Attached Tax Return
You must provide copies of the IRS Form W-2 from each employer for the 2015 tax year issued to you and/or your spouse.
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VWI6O
S
Student ID Number
For Non-Tax Filers
•
•
If you had no earnings from work, please indicate ‘NONE’.
Complete the boxes below and provide all W-2s issued to you for the year 2015
I (Student) am not required to file a 2015 federal tax return
and have provided the information below.
• List below all employers and any income you received in 2015
$
Amount
$
Amount
Employer
Employer
I (Spouse) am not required to file a 2015 federal tax return
and have provided the information below.
• List below all employers and any income you received in 2015
_
$
Amount
$
Amount
Employer
_
Employer
_
_
Student/Spouse Additional Information
In 2014 or 2015, did you, your spouse or anyone in your household receive benefits from the Supplemental Nutrition Assistance Program
(SNAP), previously known as food stamps?
□ Yes
□ No
In 2015, did you or your spouse pay child support?
□ Yes
□ No
List the total amount of child support paid for the 2015 year due to divorce or separation or as a result of a legal requirement. Do not include
support paid for children included in the household size question on the Free Application for Federal Student Aid (FAFSA).
Name of Person Who Paid
Child Support
Name of Person to Whom
Child Support Was Paid
Full Name of Child for
Whom Support Was Paid
Age of Child for
Whom Support Was
Paid
Total Amount of Child
Support Paid in 2015
Untaxed Income:
Please complete all sections below. If it does not apply to you or your spouse please indicate ‘None’ or ‘0’.
2015 Untaxed Income
$
$
a. Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including, but not limited to,
amounts reported on the W-2 forms in Boxes 12a through 12d, codes D, E, F, G, H, and S.
b. IRA deductions and payments to self-employed SEP, SIMPLE, and Keogh and other qualified plans form IRS Form 1040—total of
lines 28 + 32 or 1040A—line 17.
c. Child support you received for all children for the entire 2015 year. Don’t include foster care or adoption payments.
$
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VWI6O
S
Student ID Number
$
$
$
$
$
$
d. Untaxed portions of IRA distributions from IRS Form 1040—lines (15a minus 15b) or 1040A—lines (11 a minus 11 b).
Exclude rollovers. If negative, enter a zero here.
e. Untaxed portions of pensions from IRS Form 1040—lines (16a minus 16b) or 1040A—lines (12a minus 12b).
Exclude rollovers. If negative, enter a zero here.
f. BAS - food and other living allowances paid to members of the military, housing for clergy, and others (including cash
payments and cash value of benefits). You can get this amount from your 2015 December Leave Earnings Statement (LES). Don’t
include the value of on-base military housing or the value of a basic military allowance for housing. Note: (multiply by # of months you
received – it might not always be 12)
g. Veterans’ non-education benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC), and/or VA
Educational Work-Study allowances.
h. Any other untaxed income not reported elsewhere. This can include disability (but not Social Security disability), worker’s
compensation, interest income on education IRAs, untaxed portions of Railroad Retirement benefits, black lung benefits, refugee
assistance, the untaxed portion of capital gains, and foreign income that wasn’t taxed by any government and isn’t part of the Foreign
Earned Income Exclusion.
i. Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form. If someone is paying rent, utility bills,
etc., for you while you attend school, include the amount of that person’s contributions.
TOTAL Annual Untaxed Income for 2015
$
In 2014 OR 2015, did you or anyone in your household receive assistance from any of these Federal benefits programs? Please check all
that apply:
Supplemental Security Income
Free or Reduced Price School Lunch
WIC
Temporary Assistance for Needy Families (TANF)
Special Information
If your household income (untaxed plus taxable income) was low for a family of your size and you did not receive any of the benefits or
assistance listed above, please explain how your family met household expenses and provide an annual dollar amount of assistance received
from other sources. If someone pays expenses on your behalf, please indicate the specific dollar amount they pay annually. Attach an
additional page if needed. If you were incarcerated in 2015, please provide dates and explain the income situation for that time.
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Note: Additional required documentation may be requested by the Financial Aid Office.
By signing this document, I certify that the information is complete, true and accurate. I understand that purposely providing false or misleading
information could result in criminal prosecution, a prison sentence, and/or a fine pursuant to U.S. Criminal Code and Colorado Criminal Code.
Student Signature:
________________Date:________________________
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Arapahoe Community College
Financial Aid Office
5900 S Santa Fe Drive
Littleton, CO 80160-9002
303-797-5661
Fax: 303-797-5663
[email protected]
Colorado Northwestern
Community College
500 Kennedy Drive
Rangely, CO 81648-3502
970-675-3204
Community College of Denver
Financial Aid Office
P.O. Box 173363, Box 206
Denver, CO 80217
303-556-5503
[email protected]
Front Range Community College
Financial Aid Office
Larimer: 970-204-8376
Boulder: 303-678-3696
Westminster: 303-404-5250
[email protected]
Morgan Community College
Financial Aid Office
920 Barlow Road
Fort Morgan, CO 80701-4371
970-542-3150
[email protected]
Northeastern Junior College
Financial Aid Office
100 College Drive
Sterling, CO 80751
970-521-6751
[email protected]
Pikes Peak Community College
Financial Aid Office
Centennial Campus Location
5675 South Academy Boulevard
Colorado Springs, CO 80906-5422
719-502-3000
Pueblo Community College
Financial Aid Office
900 West Orman Ave Pueblo,
CO 81004-1430
719-549-3020 (financial aid)
719-549-3200 (general inquiry)
Trinidad State Junior College
Financial Aid Office
600 Prospect Street
Trinidad, CO 81082-2356
Trinidad: 719-846-5553
Alamosa: 719-589-7024
Community College of Aurora
Financial Aid Office
16000 East Centre Tech Parkway
Aurora, CO 80011-9036
303-360-4709
[email protected]
Lamar Community College
Office of Financial Aid
2401 South Main Street
Lamar, CO 81052-3912
719-336-1590
[email protected]
Otero Junior College
Financial Aid Office
1802 Colorado Avenue
La Junta, CO 81050-3346
719-384-6834
Red Rocks Community College
Financial Aid Office
13300 West Sixth Avenue
Lakewood, CO 80228-1255
303-914-6256
Fax: 303-914-6805
[email protected]