V1 Verification Form Page 2
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2Student Name:____________________________________________ ASU ID Number:____________________________________
2012 Tax Information
Parent/Step-Parent or Student’s Spouse
Student Information:
Information:
Check one box only:
Check one box only:
I used the FAFSA IRS Data Retrieval Tool to electronically
I used the IRS Data Retrieval Tool to transfer 2012 tax
transfer 2012 tax information on the FAFSA.
information on the FAFSA.
I am unable or choose not to use the IRS Data Retrieval
I am unable or choose not to use the IRS Data Retrieval
Tool in FAFSA on the Web. I am submitting a copy of my
Tool in FAFSA on the Web. I am submitting a copy of my
2012 IRS Tax ReturnTranscript.
2012 IRS Tax Return Transcript.
I filed an amended 2012 tax return or an extension and
I filed an amended 2012 tax return or an extension and
will contact the Financial Aid office for further instruction.
will contact the Financial Aid office for further instruction.
I will NOT* file and/or am NOT required to file a 2012
I will NOT* file and/or am NOT required to file a 2012
U.S. Income Tax Return. (complete the income section below)
U.S. Income Tax Return. (complete the income section below)
*Non-Filers ONLY - Income Information (You must provide all W-2 forms or other earning statements)**
Employer Name
Student/Spouse
Parent(s)
W-2
Note: In most cases, earning above $5,800 requires a tax return to be filed.
2012 Amount Earned
2012 Amount Earned
Attached
$
$
$
$
$
$
$
$
** If you you have low or zero income for 2012, we may request additional information to verify your income.
Child Support Information
If you paid court mandated Child Support in 2012, please complete the following information.
Check here if no Child Support was paid.
Name of Person Who
Name of Person to Whom
Name of Child for Whom
Amount of Child Support
Paid Child Support
Child Support was Paid
Support was Paid
Paid in 2012
Marty Jones(example)
Chris Smith(example)
Terry Jones
$6,000.00
$
$
$
$
$
Untaxed Income Information
Student/Spouse
Parent(s)
Sources of Untaxed Income
2012 Information
2012 Information
Yes
No
N/A
Yes
No
N/A
I rolled over an IRA Distribution in 2012.
Yes
No
N/A
Yes
No
N/A
I rolled over a Pension Distribution amount in 2012.
By signing this Verification Statement, I (we) certify that all information reported is complete and accurate. WARNING: If
you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
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