Financial Aid & Scholarships 2015-16 V4 Verification Form (Page 2 of 3) in pdf

Financial Aid & Scholarships 2015-16 V4 Verification Form Page 2

Arkansas State University-Newport

Financial Aid & Scholarships

2015-16 SnapVerification Form

__________________________________________________________________

If you reported on the FAFSA that you received SNAP benefits, this form must be completed by you and DHS

personnel then submitted to the Financial Aid Office.

If you did not report SNAP benefits on the FAFSA you do not need to complete this form.

Students selected for verification must submit additional information for review. Part of this process includes providing verification that a member

of the student’s household received SNAP benefits during 2014 or 2015.

This form must be completed by the Department of Human Services

(DHS) in order to verify receipt of SNAP benefits.

Student name (Last name, first name)

ASUN ID number

Cell phone number

Household member that received SNAP (Last name, first name)

Student’s relationship to household member (i.e., Mother, Father, etc.)

Indicate here if no SNAP benefits were received.



No person in the student’s household received SNAP benefits during 2014 or 2015.

Indicate here if SNAP benefits were received – Certificate of Receipt – To be completed by DHS.

This is to certify that ________________________________________ received Supplemental Nutrition Assistance Program benefits during

the year indicated below:



2014



2015

___________________________________________________________

Printed Name of DHS Employee

_________________________________________________________________

___________________________________________________________

Signature of DHS Employee

Date

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.

Student Signature

Date

Student’s Spouse or Parent Signature

Date

Financial Aid & Scholarships 2015-16 V4 Verification Form Page 2