Verification Worksheet (Page 4 of 5) in pdf

Student SU ID#: _800____________________

SECTION F.

Additional Financial Information

Complete the 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 1/1/2015 through 12/31/2015

Parent

Student

E.1: Taxable earnings from need-based employment programs, such as Federal Work-Study, cooperative

education program and need-based employment portions of fellowships and assistantships.

E.2: 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).

Don’t include foster or adoption payments.

E.3: Child Support received for all children.

E.4: Housing, food and other living allowances paid to members of the military, clergy and others

(including cash payments and cash value of benefits).

E.5: Veterans non-education benefits such as Disability, Death Pension, or dependency & Indemnity

Compensation (DIC) and/or VA Educational Work-Study allowances.

E.6: Any other untaxed income or benefits not reported above, such as worker's compensation, disability,

etc. Explain:

SECTION G.

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 and referral to the

appropriate authorities. This document must be postmarked by June 1, 2016 to be considered for maximum eligibility of aid.

Student Signature

Date

Parent Signature

Date

** If you fax this form, please fax both sides.

NOTIFICATION:

Awards and payments will not be available until we have reviewed your documents and verified your eligibility. For more information

please go to

DVERIF_1617

RV 3/8/16

Verification Worksheet Page 4