Additional Resources Verification Form - Dependent
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1ADDITIONAL RESOURCES VERIFICATION FORM
Financial Aid Services
DEPENDENT (V6)
2016-2017
PART I: STUDENT INFORMATION
Name: __________________________________________________________________
SPIRE ID: _____________________________
Last
First
Middle
Date of Birth: _____/_____/_______ Phone Number: (
) ______-________ Email Address:_____________________________________________
PART II: OTHER INCOME INFORMATION
Please report below any amount received in 2015 by you and your parent(s). Report total amount received for the entire year.
Do not include student fi nancial aid received. You must check yes or no for each question in order for the form be considered complete.
Did you or your parent(s)...
Parent(s)
Student
...get money or have bills paid by someone not in the household?
No
Yes Amount $_________
No
Yes Amount $_________
...receive tax-exempt interest income from investments?
Yes Amount $_________
No
Yes Amount $_________
No
...receive foreign income (income from another country)?
Yes Amount $_________
No
Yes Amount $_________
No
...receive any other forms of income? if yes, explain: _______________________
Yes Amount $_________
No
Yes Amount $_________
No
...make withdrawal from a retirement account (IRA, pension) or other type of
Yes Amount $_________
No
Yes Amount $_________
No
retirement account?
...make payments to tax-deferred pension and savings?
Yes Amount $_________
No
Yes Amount $_________
No
...pay into a health (medical) savings account?
Yes Amount $_________
No
Yes Amount $_________
No
...receive an inheritance?
Yes Amount $_________
No
Yes Amount $_________
No
...receive money as benefi ciary of a trust fund?
Yes Amount $_________
No
Yes Amount $_________
No
...receive fi nancial support from a church or charitable organization?
Yes Amount $_________
No
Yes Amount $_________
No
Receive income or benefi ts from the government/state in any of the following forms?
Low Income Housing/Section 8
Alternative Housing Voucher Program AHVP
Yes Amount $_________
No
Yes Amount $_________
No
Massachusetts or other state Rental Voucher Program (MRVP)
Railroad Retirement Benefi ts
Yes Amount $_________
No
Yes Amount $_________
No
Black Lung Benefi ts
Yes Amount $_________
No
Yes Amount $_________
No
If you answered No to all the questions above, you must explain below what resources were used to support the household fi nancially in 2015:
(e.g. How were housing, food, heat, insurance, taxes, and other fi nancial obligations met?)
PART III: CERTIFICATION
By my signature, I certify that all information submitted with and written on this application is complete, accurate, and corrections may be made based on data provided, and that
if I purposely give false or misleading information on this worksheet, I may be fi ned, sentenced to prison, or both.
Parent Signature: __________________________________________ Student Signature: ___________________________________ Date: _______________
Document must be signed with a real signature. Digital signatures are not accepted.
Fax completed, signed form to: 413-545-1700
or email completed, signed form to: fadocs@fi naid.umass.edu
(Attachments must be a standard image fi le, or in one of the following fi le formats: .doc, .docx, .pdf)
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