2016-17 Academic Year

Verification Statement - ndependent Student

D C D Student s ame

Please complete, print, sign, and submit this form.

e 1 - de rma i

ddress include apt. Date of irth

Cit State ip Code

Student s Primar Phone include area code Student s Primar -mail ddress

e 2 - e d rma ieport elo

ourselfour spouse if ou are marriedour children if ou ill pro ide more than half of their support from ul , through

une , ther people onl if the li e ith ou and ou pro ide more than half of their support and

ill continue to do so from ul , through une , Pro ide college information for those students attending at least half-time during - in

a program leading to a degree, diploma, or certificate

e - e d a ed c me a d e e i - a e dar Year 201 Did ou or others in our household recei e unta ed income in

Y Complete the nta ed ncome section at the end of this form.

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e - de a i i a - a e dar Year 201a e ou or ill ou be re uired to file a .S. federal income ta return

Y

ad me ear i r m r - Submit a Non-Tax Filer's Statement a ailable on the dashboard. e sure to submit all - and forms ou recei ed.

a d ad ear i r m r - Submit a Non-Tax Filer's Statementa ailable on the dashboard.

e - e a i i a - a e dar Year 201f ou are married, has our spouse filed or ill he or she be re uired to file a .S. federal income ta return

Y

e r e ad me ear i r m r - Submit a Non-Tax Filer's Statement on the dashboard. e sure to submit all - and forms he or she recei ed.

a d e r e ad ear i r m r - Submit a Non-Tax Filer's Statement a ailable on the dashboard.

e 6 - d am e e i - a e dar Year 201 a d 201Did ou recei e Supplemental utrition ssistance Program S P benefits ood Stamps in or

Y Submit a cop of a letter or other documentation from the agenc that issued the ood Stamps our famil recei ed. f our college has gi en ou guidance, please follo their directions. Clearl label the document ood Stamp Verification and put our SS in the top right corner of the document.

e 7 - i d r aid - a e dar Year 201Did ou, or our spouse if married, pa child support because of di orce or separation during the calendar ear Do not include support for children included in Step abo e

Y Complete, and submit in our D C pac et, a Child Support Paid Verification Statement a ailable on the dashboard.

e - er i ica i certif all the information reported is complete and correct the student and student s spouse, if married, must sign

Student Signature Date

Spouse Signature if married Date

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eri ica i de a ed c me r 201

c m e e a d re r i ec i i a ered Ye i e

er annual am r a ica e i em f an item does not appl , enter for ot pplicable here a re e is re uested and in an area here an am is re uested.

f more space is needed, pro ide a separate page ith the student s name and D C D at the top.

A a me a -de erred e i a d re ireme a iist pa ments direct or ithheld from earnings to ta -deferred pension and retirement sa ings

plans e.g., or b plans , including, but not limited to, amounts reported on - forms ino es a through d ith codes D, , , , , and S.

i d r recei edist of the actual amount of child support recei ed in for the children in our household.

i c de foster care pa ments, adoption pa ments, or an amount that as court-ordered but not actuall paid.

i d a d er i i a a ce aid mem er e mi i arc er a d er

nclude cash pa ments and or the cash alue of benefits recei ed.

i c de the alue of on-base militar housing or the alue of a basic militar allo ance for housing.

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e era -ed ca i e e iist the total amount of eterans non-education benefits recei ed in . nclude Disabilit ,

Death Pension, Dependenc and ndemnit Compensation D C , and or V ducational or -Stud allo ances.

i c de federal eteran s educational benefits such as ontgomer ill, Dependents ducation ssistance Program, V P enefits, or Post- ill.

er a ed i c meist the amount of other unta ed income not reported and not e cluded else here on this form.nclude unta ed income such as or ers compensation, disabilit , lac ung enefits, ailroadetirement enefits, etc.

i c de an items reported or e cluded in - D abo e. n addition, do not include student aid, arned ncome Credit, dditional Child a Credit, emporar ssistance to eed amilies

, unta ed Social Securit benefits, Supplemental Securit ncome SS , or force n estment ct educational benefits, combat pa , benefits from fle ible spending arrangements e.g., cafeteria plans , foreign income e clusion, or credit for federal ta on special fuels.

e recei ed r aid e de e aist an mone recei ed b or paid on the student s behalf e.g., if someone is pa ing rent, utilit

bills, etc., for the student or gi es cash, gift cards, etc. not reported else here on this form. nterthe total amount of cash support the student recei ed in . mounts paid on the student sbehalf also include an distributions to the student from a plan ed me e er

a e de r e de are such as grandparents, aunts, and uncles.

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