2014-2015 Verification Worksheet Template Page 3
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2
3Student Name________________________________________________________
Student ID____________________________
Supplemental Nutrition Assistance Program Benefits Received by Student or Parent
If you or someone in your household as indicated above, received benefits from the Supplemental Nutrition Assistance Program or SNAP
(formerly known as food stamps) any time during the 2012 or 2013 calendar years, please list which family member(s) below. Supporting
documentation may be requested.
Name of Family Member(s):
________________________________________________
________________________________________________
________________________________________________
Child Support Paid by Student and Spouse (if married)
Did you, the student, or your spouse, pay child support because of divorce or separation during the calendar year 2013? (Do not include
support for children included in household size in section B.) If asked by the school, I 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 student ID 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
2013
Marty Jones
Chris Smith (example)
Terry Jones
$6,000.00
Child Support Paid by Parent
Did you, the parent, pay child support because of divorce or separation during the calendar year 2013? (Do not include support for
children included in household size in section B.) If asked by the school, I 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 student ID 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
2013
Marty Jones
Chris Smith (example)
Terry Jones
$6,000.00
Sign this Worksheet
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. The student and at least one
parent must sign and date. WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be
sentenced to jail, or both.
_________________________________________________________
_________________________________________________________
Student
Date
Parent
Date
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