ID ___________
RD ___________
2011-2012 Dependent Institutional Verification Form
OFFICE OF FINANCIAL AID
100 College Drive • Kankakee, IL 60901-6505 • (815) 802-8550 • FAX: (815) 802-8551
Student’s Name
Address
Last
First
MI
Street (include apartment number)
Soc. Sec. #
City
Date of Birth
State
Zip
Phone Number
The information you provided on your Free Application for Federal Student Aid (FAFSA) must be verified before Financial Aid eligibility
can be calculated. Complete the applicable sections of this form and fax it to (815) 802-8551 or return it to the address listed above.
Failure to complete this form will delay your financial aid award letter.
A. Family Information
Complete this section with information about the persons your parent will support between July 1, 2011 – June 30, 2012. Include
yourself, your parent(s), step-parent (if legally married), and parent’s other children if they receive more than half of their support from
your parent(s).* Do not include foster children. Include other persons only if they now live with your parent(s) and receive more
than half of their support from them, and will continue to receive the support between July 1, 2011 –June 30, 2012.*
Full name of person in household
Age
Relationship to student
Self
Name of college if attending half-time or more and
will be enrolled in a degree or certificate program
between July 1, 2011 – June 30, 2012.
(Do not include parent’s college)
Kankakee Community College
□ Check this box if there are more than seven family members in your household and attach a list of these people.
* If your siblings are over the age of 24 or your parent(s) have dependents other than their children, additional documentation will be
required at a later date.
B. Student Information (all applicants)
1. If you filed or will file a 2010 Federal U. S. 1040, 1040A, 1040EZ, or foreign income tax return, you must submit a signed
copy of the return to our office.
2. If your tax return is not attached, please indicate the reason in one of the boxes below.
□ I have already submitted a copy of my 2010 federal income tax return to the Office of Financial Aid.
□ I will not and am not required to file a 2010 federal income tax return.*
*If you are not required to file, list below your employer(s) and/or any income (cash) received from work in 2010 (use the W-2 form
or other earnings statements if available).
Sources (employer)
2010 Income (include cash earned from work)
$
$
C. Parent Information
1. If you and/or spouse filed or will file a 2010 Federal U. S. 1040, 1040A, 1040EZ, or foreign income tax return, you must submit a
signed copy of the return to our office.
2. If you and/or your spouse’s tax return are not attached, please indicate the reason in one of the boxes below.
□ You and/or your spouse already submitted a copy of his/her 2010 Federal U. S. 1040, 1040A, 1040EZ, or foreign income
tax return to the Office of Financial Aid.
□ I, mother/step-mother of the student, am not required to file a 2010 Federal U. S. 1040, 1040A, 1040EZ, or foreign
income tax return.*
□ I, father/step-father of the student, am not required to file a 2010 Federal U. S. 1040, 1040A, 1040EZ, or foreign
income tax return.*
*If you and/or your spouse are not required to file, list below his/her employer(s) and/or any income (cash) from work received in
2010 (use the W-2 form or other earnings statements if available).
Sources (employer)
2010 Income (include cash earned from work)
$
$
D. Student and Parent Additional Financial Information
1. Please indicate any other income and/or benefits that were not subject to taxes that you and your parent(s) received
during 2010. Please refer to the “untaxed income” questions on the FAFSA. (Please enter “0” if not applicable)
Type of Untaxed Income/Benefit
Student Totals for 2010
Parent Totals for 2010
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).
Child support RECEIVED for ALL children. Do not include foster care or adoption
payments.
$
$
$
$
Housing, food and other living allowances paid to members of the military, clergy
and others (including cash payments and cash value of benefits.) Don’t include
the value of on-base military housing or the value of a basic military allowance for
housing.
Veterans non-education benefits, such as Disability, Death Pension, or Dependency
& Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.
Other untaxed income not reported above, such as workers’ compensation,
disability, etc.
Money received or money paid on your behalf (e.g. bills), and not reported
elsewhere on this form.
$
$
$
$
$
$
$
2. If you were not required to file a 2010 federal tax return, please indicate below any other types of income assistance that
you and your parent(s) received during 2010. Please enter “0” if not applicable
Income
Student Totals for 2010
Parent Totals for 2010
Unemployment Compensation
$
$
Social Security Disability
$
$
Supplemental Social Security
$
$
Other types of Social Security (Retirement)
$
$
Welfare/TANF (cash assistance only)
$
$
Food Stamps (Link card)
$
$
□
□
□
□
3. Did you or your parent(s) have a state medical card?
Student
Yes
No
Parent
Yes
No
If you and/or your parent had no/low income in 2010, we are required to ask for additional documentation at a later date.
E. Sign the Worksheet
Each person signing this form certifies that all the information reported is complete and accurate.
Student Signature
Parent Signature
Date