Form 3 - Child Support Verification Worksheet - 2015-2016

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2015-2016
Form #3 - Child Support Verification Worksheet
Your Free Application for Federal Student Aid (FAFSA) was selected for review in a process called “Verification”.
In this process we compare your FAFSA with information on this worksheet and other required documents, such
as your 2014 IRS tax information. The Financial Aid Staff will not make any financial aid payments to you until all
verification and required documentation have been met and the necessary correction have been made under the
financial aid program regulation (34CFR, art 668).
STUDENT INFORMATION
Last Name (Please Print)
First Name
M.I.
Date of Birth
Social Security #
Peralta Student ID
Telephone Number to best reach you
CHILD SUPPORT PAID
Did you, your spouse (if married) or parent(s) (if required to provide parent information on the FAFSA), indicate
that child support was paid on the FAFSA in 2014? If yes, please complete the information below.
Name of Person Who
Name of
Name of Child
Amount Paid in 2014
Paid Child Support
Person/Agency Paid
Note: We may require additional documentation before we can determine your eligibility.
• A copy of the separation agreement or divorce decree that shows the amount of child support to be
provided;
• A statement from the individual receiving the child support certifying the amount of child support received; or
• Copies of the child support payment checks or money order receipt or similar records of electronic payments
having been made.
SIGN THE WORKSHEET
By signing below, I/we certify the information reported on this worksheet is complete and accurate and authorize the Financial Aid Office to
perform necessary electronic ISIR correction on my behalf. I/we agree to provide proof of any information reported on this form or on my
FAFSA. I/we realize that any false statement or failure to give proof when asked may be cause for denial, reduction, withdrawal, and/or
repayment of my financial aid. I/we also understand if we purposely give false or misleading information I/we may be fined, sentenced to jail
or both. If you are a dependent student, one parent must sign below.
Student’s signature
Date
Spouse’s Signature (if married) Parent’s Signature (if a dependent student) Date
Laney College
Merritt College
College of Alameda
Berkeley City College
900 Fallon Street
12500 Campus Drive
555 Ralph Appezzato Mem.Pkwy
2050 Center Street
Oakland, CA 94607
Oakland, CA 94619
Alameda, CA 94501
Berkeley, CA
510.464.3314
510.436.2465
510.748.2228
510.981.2805

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