F5VFWK 1415 2014-2015 VERIFICATION WORKSHEET Your application was selected for review in a process called Verification. During this process we will be comparing information from your FAFSA with this worksheet and with your 2013 Federal Income Tax information. Should there be differences between your FAFSA and the information that you provided to our office, we will make those corrections to your FAFSA. We reserve the right to ask for further clarification and to request additional information under Federal financial aid program guidelines (CFR title 34, Part 668). To protect your privacy, please make sure every document you submit is labeled with the student’s name! A: Student Information ________________________________________________________ Last Name First Name M.I. ________________________________________________________ Street (apt #) For income verification we can only accept a direct data transfer from the IRS to your FAFSA or the official IRS Tax Transcript (no 1040 forms). The IRS Data Retrieval Tool provides real time data transfer for your verification! ________________________________________________________ City State Zip Code ________________________________________________________ Date of Birth Last 4 SSN Student ID # To easily complete the Data Transfer just log into your FAFSA and click on the secure IRS Data Retrieval tool located in the Financial Information Section. [email protected] E-mail address If you can not do the online data transfer, then you can calling 800-908-9946 to request an official tax transcript or you may print your own at: http://www.irs.gov/Individuals/Get-Transcript ________________________________________________________ Best Phone Number to reach you B: Family Information If you are a Dependent Student, include:  Yourself and your parent(s) (including stepparent) even if you don’t live with your parents, and  Your parent(s) dependent children, if your parents will provide more than half of their support from July 1, 2014 through June 30, 2015. If you are an Independent* Student, include:  Yourself and your spouse (if married)  Your dependent children, if you will provide more than half of their support from July 1, 2014 through June 30, 2015. Include other people as part of your household only if they now live with you (or your parent(s), if dependent) and if you or your parent(s) will be providing more than half of their support between July 1, 2014 through June 30, 2015. * A student is considered Independent only if any of the following are true: 1) was born before 1/1/91; 2) will be enrolled in a graduate program; 3) is married; 4) was an orphan or ward of the court after the age of 13; 5) has a child; 6) has a legal dependent; 7) has a court appointed legal guardian; 8) is determined by state agency to be homeless; 9) is a court approved emancipated minor; 10) is on active duty or is a veteran; Full Name of student and family members Age Relationship to you (attach separate sheet if more space is needed) Your name: SELF If attending college at least half time (except for parent) please write the name here: Salem State University PLEASE CONTACT US WITH ANY QUESTIONS. YOU MUST RETURN THIS FORM WITH ALL SUPPORTING DOCUMENTS. By Mail: Salem State University Financial Aid Office 352 Lafayette Street Salem, Ma 01970 In person: 1st floor, Admin building, North Campus By Fax: 978.542.6876 By Email: [email protected] NOTE: DELAY IN RESPONDING OR RETURNING THIS FORM MAY RESULT IN LOSS OF FINANCIAL AID. C: Federal Tax Return Information Student (and Spouse) please check one box:   I/we have filed a 2013 Federal Income Tax Return and either used the IRS Data Retrieval option through fafsa.gov or I have attached an official copy of my IRS Tax Return Transcript. (See instructions to do data transfer or request a transcript on page one of this form)  I/we did not and am not required to file a 2013 Federal Income Tax Return. Any wages earned, but not filed, are indicated in worksheet below.  I/we have not filed 2013 Federal Income Taxes as of this date, but will be filing Federal Income Tax Returns. I understand that to complete this verification process, once my/our tax returns are filed, I / we must update FAFSA online by selecting the IRS Data Retrieval option, if eligible, or I / we will request and send in our 2013 Federal IRS Official Tax Return Transcript. (See instructions to do data transfer or request a transcript on page one of this form) Parent (required, if dependent) please check one box:  I/we have filed a 2013 Federal Income Tax Return and either used the IRS Data Retrieval option through fafsa.gov or I have attached an official copy of my IRS Tax Return Transcript. (You may request an IRS Tax Return Transcript by calling 800.908.9946)  I/we did not and am not required to file 2013 a Federal Income Tax Return. Any wages earned, but not filed, are indicated in worksheet below.  I/we have not filed 2013 Federal Income Taxes as of this date, but will be filing Federal Income Tax Returns. I understand that to complete this verification process, once my/our tax returns are filed, I / we must update FAFSA online by selecting the IRS Data Retrieval option, if eligible, or I / we will request and send in our 2013 Federal IRS Official Tax Return Transcript. (See instructions to do data transfer or request a transcript on page one of this form) D: Federal Untaxed Income, Benefits and Income Exclusions PLEASE USE ANNUAL AMOUNTS FOR 2013. Do not leave any spaces blank – if the answer is ZERO, write the number, “0” Student/Spouse Parent(s) Social Security Benefits received that were not taxed (such as SSI). Welfare benefits, including Temporary $ $ Assistance to Need Families (TANF). Do not include food stamps or subsidized housing. List tax exempt interest income from IRS Form 1040 – line 8b or 1040A-line 8b. $ $ $ $ $ $ $ $ $ $ $ $ $ Enter untaxed portions of IRA distributions from IRS Form 1040 – lines (15a minus 15b) or 1040A – lines (11a minus 11b), excluding rollovers. Enter payments to tax-deferred pension and savings plan paid directly or withheld from earnings, including amount reported on your W-2 form in Boxes 12a through 12d, codes D,E,F,G,H or S. Enter IRA Deductions and payments to self-employment SEP, SIMPLE and Keogh. $ Untaxed portions of pensions from IRS 1040 – lines (16a minus 16b) or 1040A – lines (12a minus 12b), excluding rollovers. Enter Child support received for all children. Do not include foster or adoption payments. $ Enter housing, food and other living allowances paid to members of the clergy, military, and others. (Including cash payments and cash value of benefits). Enter Veteran’s non-education benefits, such as Disability, Death Pension, DIC, and/or VA Educational WorkStudent Allowance. Any other untaxed income and benefits not reported elsewhere, such as worker’s compensation, untaxed portion of Railroad Retirement Benefits, Black Lung Benefits, and Refugee Assistance - do not include student financial aid. Enter cash received or any money paid on your behalf, not reported elsewhere on this form. $ Enter untaxed wages earned but not reported on a federal income tax return. I will submit copies of my W-2 forms with this verification form. INCOME EXCLUSIONS Taxable earnings from Federal Work-Study or other need based work programs earned in 2013. $ $ $ $ $ $ XXXXXXXXX $ Combat pay or special combat pay. Only enter the amount that was taxable and included in your adjusted gross income (AGI). DO NOT enter untaxed combat pay reported on the W-2 (box 12, Code Q). $ E: Additional Financial Questions: Yes Do you (or your parents if a dependent student) have income from a rental or vacation property (line 17 on 1040) If yes, you must submit a Property Verification Worksheet (available on our website) No Yes Do you (or your parents if a dependent student) have a zero or a negative adjusted gross income (AGI) on your (their) Tax Return? If yes you must submit an Income Expense Worksheet (available on our website) No E: Signature Required By signing this worksheet, I/we certify that all the information reported on it is complete and correct. If student is Dependent, one parent must sign this form. _________________________________________________________________ Student signature Date _________________________________________________________________ Parent Signature (required, for a dependent student) Date Note: Delay in returning this form can result in loss of financial aid.