Verification Worksheet, V6-D - Southwestern Adventist University Page 3
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4Student’s Name: ______________________________________________ ID#: __________________________
D. Parent’s Other Information to Be Verified
1. Complete this section if someone in the student’s parent’s household (listed in Section B) received benefits from the
Supplemental Nutrition Assistance Program or SNAP (formerly known as food stamps) any time during the 2013 or 2014
calendar years.
One of the persons listed in Section B of this worksheet received SNAP benefits in 2014 or 2015. If asked by the student’s
school, I will provide documentation of the receipt of SNAP benefits during 2014 and/or 2015.
2. Complete this section if one of the student’s parents paid child support in 2015.
One (or both) of the student’s parents listed in Section B of this worksheet paid child support in 2015. Listed below is the
name of the person who paid the child support, the name of the person to whom the child support was paid, the names of
the children for whom child support was paid, and the total annual amount of child support that was paid in 2015 for each
child. If asked by the school, the parents will provide documentation of the payment of child support. If you need more
space, attach a separate page that includes the student’s name and ID# at the top.
Name of Person Who
Name of Person to
Name of Child for
Age of Child for
Amount of Child
Paid Child Support
Whom Child Support
Whom Support was
Whom Support was
Support Paid in
was Paid
Paid
Paid
2015
Joe Jones
Chris Smith
Terry Jones
4 years
$6000.00
(example)
E. Certification and Signatures
Each person signing this worksheet certifies that all of the
WARNING: If you purposely give false or misleading
information reported on it is complete and correct.
information on this worksheet, you may be fined, be
The student and one parent must sign and date.
sentenced to jail, or both.
_________________________________________________
_________________________________
Student’s Signature
Date
_________________________________________________
_________________________________
Parent’s Signature
Date
Do not mail this worksheet to the U.S. Department of Education.
Submit this worksheet to Student Financial Services at SOUTHWESTERN ADVENTIST UNIVERSITY.
You should make a copy of this worksheet for your records.
omplete and sign Section F on the last page.
*Be sure to c
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