2014-2015 Standard Verification Worksheet Template (V1) Independent Student Page 3
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3Student’s Name: _______________________________________ CWID: ________________________________
D. Independent Student’s Other Information
1) Complete this section if someone in your household (listed in Section B) received benefits from the Supplemental
Nutrition Assistance Program or SNAP (formerly known as the Food Stamp Program) sometime during 2012 or 2013. SNAP
may be known by another name in some states. For assistance in determining the name used in a state, please call 1-800-4FED-
AID (1-800-433-3243).
One of the persons listed in Section B of this worksheet received SNAP benefits in 2012 or 2013. If asked by my school, I
will provide documentation of the receipt of SNAP benefits during 2012 and/or 2013.
2) Complete this section if you or your spouse, if married, paid child support in 2013.
Either I, or if married my spouse who is listed in Section B of this worksheet, paid child support in 2013. 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
name of the child for whom child support was paid, and the total annual amount of child support that was paid in 2013
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 CWID number at the top.
Name of Person Who Paid
Name of Person to Whom Child
Name of Child for Whom Support
Amount of Child
Child Support
Support was Paid
Was Paid
Support Paid in
2013
Note: If we have reason to believe that the information regarding child support paid is not accurate, we may require additional
documentation, such as:
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 receipts.
E. Certification and Signature
I certify that all information reported on this form and on any attachments
WARNING: If you purposely give false or misleading
is complete and correct. If requested, I agree to provide documentation
information you may be fined, be sentenced to jail, or
to support the information I have provided on this form.
both.
_____________________________________________
________________________________
Student’s Signature (Required)
Date
_____________________________________________
________________________________
Spouse’s Signature (Optional)
Date
Please mail, fax, or scan and email all required documentation to the GSEP Financial Aid Office:
th
6100 Center Drive, 5
Floor
Los Angeles, CA 90045
Phone: 310-568-5775
Fax: 310-568-2399
Email: GSEPfaid@pepperdine.edu
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