Verification Form Dependent Salisbury University Page 2
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1
2C. Student’s Income Information
Dependent
1.
____ I will file or have already filed a 2012 U.S. Income Tax Return. Attach all 2012 W-2(s). (check box, go to number 2)
or
____ I will not file and am not required to file a 2012 U.S. Income Tax Return. (check box, answer a, b, or c, then go to number 2)
a.
____ I was not employed in 2012.
b.
____ I was employed in 2012. You are required to attach all W-2’s to this document.
c.
____ I was employed in 2012 and was not issued a W-2(s). Please explain why you do not have a W-2(s).
Explanation: _________________________________________________________________ Amount of income received: $ ________
2.
Other Untaxed Income Amounts Received. If none, you must write “0" in 2012 Amount sections.
Amount of Untaxed Income Received
2012 Amount
Other Source of Untaxed Income Received
2012 Amount
W-2 forms Boxes 12a through 12d, codes D, E, F, G, H and S
Child Support Received
____ I did not receive Supplemental Nutrition Assistance Program (SNAP) in 2011 or 2012.
3.
____ I did receive Supplemental Nutrition Assistance Program (SNAP) in 2011 or 2012. You are required to attach documentation from the
agency that issues the benefit.
D. Parent(s) Income Information
1.
____ I will file or have already filed a 2012 U.S. Income Tax Return. Attach all 2012 W-2(s). (check box, go to number 2)
or
____ I will not file and am not required to file a 2012 U.S. Income Tax Return. (check box, answer a, b, or c, then go to number 2)
a.
____ I was not employed in 2012.
b.
____ I was employed in 2012. You are required to attach all W-2’s to this document.
c.
____ I was employed in 2012 and was not issued a W-2(s). Please explain why you do not have a W-2(s).
Explanation: ________________________________________________________________ Amount of income received: $ ________
2.
Other Untaxed Income Amounts Received. If none, you must write “0" in 2012 Amount sections.
Amount of Untaxed Income
2012 Amount
Other Source of Untaxed Income
2012 Amount
W-2 Boxes 12a through 12d, codes D, E, F, G, H and S
Child Support Received
3.
____ I did not receive Supplemental Nutrition Assistance Program (SNAP) in 2011 or 2012.
____ I did receive Supplemental Nutrition Assistance Program (SNAP) in 2011 or 2012. You are required to attach documentation from the
agency that issues the benefit.
____ I/my spouse did not pay, was not required to pay child support in 2012.
4.
____ I/my spouse PAID child support in 2012 because of a divorce or separation or as a result of a legal requirement.
a.
The amount of child support paid in 2012 $_______.
The name(s) of the children for whom child support was paid in 2012. _____________________________________________________
b.
c.
The name and address of the person to whom child support was paid. _____________________________________________________
_____________________________________________
d.
Signature of person that paid the child support in 2012 __________________________________________________________________
E. Sign this Worksheet
DON'T FORGET TO SIGN AND DATE THIS FORM AFTER PRINTING
By signing this worksheet, we certify that all of the information reported on this worksheet is complete and correct. At least one parent must sign.
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
Parent signature
Date
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