2016-2017 Verification Worksheet Independent Student (Page 3 of 3) in pdf

Student’s Name: ______________________________________________ SSN: __________________________

D. Independent Student’s Other Information to Be Verified

1. Complete this section if someone in the student’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 2014 or 2015 calendar years.

One of the persons listed in Section B of this worksheet received SNAP benefits in 2014 or 2015. If asked by my school, I

will provide documentation of the receipt of SNAP benefits during 2014 and/or 2015.

2. Complete this section if you or your spouse, if married, paid child support in 2015.

Either I, or if married my spouse who is listed in Section B of this worksheet, paid child support in 2015. I have indicated

below 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 my school, I will provide documentation of the payment of child support. If you need more

space, attach a separate page that includes your name and Social Security Number at the top.

Name of Person Who Paid

Name of Person to Whom Child

Name of Child for Whom

Amount of Child

Child Support

Support was Paid

Support Was Paid

Support Paid in

2015

Marty Jones(example)

Chris Smith

Terry Jones

$6,000.00

E. Certification and Signature

I certify that all of the information reported on this

WARNING: If you purposely give false or misleading

worksheet is complete and correct. The student must

information on this worksheet, you may be fined, be

sign this worksheet. If married, the spouse’s signature

sentenced to jail, or both.

is optional.

_________________________________________________

_________________________________

Student’s Signature

Date

_________________________________________________

_________________________________

Spouse’s Signature

Date

Do not mail this worksheet to the U.S. Department of Education.

Submit this worksheet to the financial aid administrator at your school.

You should make a copy of this worksheet for your records.

2016-2017 Verification Worksheet Independent Student Page 3