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UCM Financial Aid Office
5200 N. Lake Road
Merced, CA 95343
Phone 209-228-4243
Fax 209-228-7861
E-mail: [email protected]
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2011-2012 DEPENDENT VERIFICATION WORKSHEET
Your file has been selected for verification of the data provided on your Free Application for Federal Student Aid (FAFSA). We cannot
evaluate your eligibility for financial aid until you submit all required verification documents. Delays in completion and submittal of this
form may result in limited funding for 2011-12. ***If needed, we reserve the right to request additional documents that are not specified on
this form***
Student UCM ID
Student Full Name
Last Name
First Name
E-mail
M.I.
Phone Number
Living Arrangements during the 2011-12 academic year (check one)
Residence Hall
Living with Parent/Relatives
Living Off Campus
Student's Tax Forms and Income Information
I have attached a complete and signed copy of my 2010 federal tax return(IRS Form 1040, 1040A, 1040EZ), including all schedules,
statements and W-2 forms.
I will NOT file a 2010 federal tax return(IRS Form 1040,1040A,1040EZ). List any income received in 2010. Please attach verification of
income received, i.e., W-2's,1099-misc,SSI Statements, etc. If no income was received please put $0. If this is left blank we will assume
your income is $0.
Parent's Tax Forms and Income Information
I/we have attached a complete and signed copy of my/our 2010 federal tax return(IRS Form 1040, 1040A, 1040EZ), including all
schedules, statements and W-2 forms.
I/we will NOT file a 2010 federal tax return(IRS Form 1040,1040A,1040EZ). List any income received in 2010. Please attach verification
of income received, i.e., W-2's,1099-misc,SSI Statements, etc. If no income was received please put $0.
(If this value is "$0" we will require additional documentation.)
Household Information
List the people in your parents household, include
· yourself, and
· your parent (s) (including stepparent)
· your parents dependent children if your parents will provide more than half their support from July 1, 2011 through June 30, 2012,
Also write in the name of the college for any household members (excluding your parents),who will be attending college at least half
time between July 1, 2011 and June 30, 2012, and will be enrolled in a degree, diploma, or certificate program. Please be aware that
we may ask you to verify the enrollment of any siblings listed below you have indicated that are enrolled in college. If you need
more space, attach a separate page.
Full Name
Date of Birth (MM,DD,YY)
Relationship
Name of Accredited
College
Please CHECK if
claimed on 2010
tax return
Self
URL:http://financialaid.ucmerced.edu
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DVERIF_1112
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2011-12
Dependent Verification
Worksheet
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Student UCM ID
Student Full Name
Last Name
First Name
M.I.
Additional Financial Information
Complete this section below if the answer is zero or the question does not apply enter "$0". Any blank entries may delay processing
of your financial aid application.
Sources of additional/untaxed income from 1/1/2010 through 12/31/2010
Child Support paid because of divorce or separation or as a result of a legal requirement. Don’t
Parent
Student
include support for children in your (or your parents’) household, as reported in question 72 of the FAFSA (refer
to question 92b of your FAFSA).
Taxable earnings from need-based employment programs, such as Federal Work-Study, cooperative
education program and need-based employment portions of fellowships and assistantships.
Student grant and scholarship aid reported to the IRS in your adjusted gross income. Include
AmeriCorps benefits (awards, living allowances and interest accrual payments, (as well as grant and
scholarship portions of fellowships and assistantships).
Child Support received for all children. Don’t include foster 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).
Veterans non-education benefits such as Disability, Death Pension, or dependency & Indemnity
Compensation (DIC) and/or VA Educational Work-Study allowances.
As of date you filed your FAFSA, what was the total amount in your cash, savings, checking accounts?
Any other untaxed income or benefits not reported above, such as worker’s compensation, disability, etc.
Explain: Don’t include, student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social
Security benefits, Supplemental Security Income, Workforce Investment Act educational benefits, combat pay, benefits form
flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion or credit for federal tax on special fuels.
Federal Benefits Information
In 2010, did you or anyone in your parents household receive benefits from any of the federal benefit programs listed? Check all that
apply, or “None” if not applicable.
Supplemental Social Security
Food Stamps
Free or Reduced Lunch
TANF
WIC
NONE
Student/Parent Certification
·
·
·
I hereby declare that all information reported on this document is true, complete, and accurate to the best of my knowledge.
I understand that any false statement or misrepresentation will be cause for denial reduction, withdrawal and/or repayment
of financial aid.
This document must by postmarked by June 1, 2011 to be considered for maximum eligibility of aid.
Student Signature
Date
Parent Signature
Date
Reminders:
■ Attach copies of all signed 2010 Federal Income Tax return (s) including all W-2s, schedules and forms.
■ Write student name and student I.D. number on all documents returned.
■ Awards will not be given until we have reviewed your documents and verified your eligibility.
■ Payments will not disburse until we have reviewed your documents and verified your eligibility.
URL:http://financialaid.ucmerced.edu
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