Verification Worksheet Template 2014-15 Page 2
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2Student Name_________________________________________
RMU ID #______________________
Student
2013 Additional Income and Financial Information
Parent
Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings),
including, but not limited to, amounts reported on the W-2 Form in Boxes 12a through 12d,
$
$
codes D, E, F, G, H, and S.
Child support RECEIVED annually for all children.
$
$
(Don’t include foster care or adoption payments)
Housing, food and other living allowances paid to members of the military, clergy and others
$
$
(including cash payments and cash value of benefits).
DON’T include the value of on-base military
housing or the value of basic military allowance for housing.
Veterans non-education benefits, such as disability, Death Pension, or Dependency &
$
$
Indemnity Compensation (DIC) and/or VA Educational Work-Study Allowances.
Other untaxed income not reported on this form, such as workers’ compensation, disability, etc.
DON’T include student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social
$
$
Security Benefits, Supplemental Security Income, Workforce Investment Act educational benefits, on-base military
housing or a military housing allowance, combat pay, benefits from flexible spending arrangements, foreign income
exclusion or credit for federal tax on special fuels.
Other money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form.
DON’T include funds provided by dependent student’s parent(s).
$
$
Source: _________________________________
Did anyone in your household receive food stamps (SNAP) in 2012 or 2013? ❑Yes ❑ No
If asked by the Financial Aid Office, please be prepared to provide supporting documentation.
In 2013 was child support PAID by any member listed in your household? ❑Yes ❑ No
If yes, complete the following information (attach a separate sheet if necessary):
Amount per
Name of person who made
Name of person who received
Name of Child
Child
payment
payment
D. Non-Tax Filer Information
If you or your parent(s) (if dependent) did NOT file a 2013Federal tax return, please report any earnings received from working
(Attach a copy of all applicable W-2 forms):
Amount Earned
Employer
Student
$
$
Parent
$
$
E. Certification
By signing below, I (we) certify that all the information reported to qualify for Federal student aid is complete and accurate. If the
student is dependent, both parent and student MUST sign.
Student
Date
Parent
Date
RETURN TO: Financial Aid Office, 6001 University Blvd, Moon Township, PA 15108
f:412.397-6499/finaid@rmu.edu
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