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Office Use Only: Ready for Review
Initial: _________ Date: ____________
Rechecked File: _______ Date: ______
Office Use Only: Initial: ________ Trans #: ________
Verified: ____/____/____
Change
No Change
Original EFC: ________
New EFC: ________
2014-2015 VERIFICATION WORKSHEET
Dependent Student V5
You have been selected by the U.S. Department of Education for a review process called Verification. This review requires you to
submit this completed worksheet, Federal Tax Return Transcripts (if requested), and other documentation to Kutztown University
Financial Aid Services, PO Box 730, Kutztown, PA 19530. Phone: 610-683-4077. DO NOT FAX. Please make sure all necessary
signatures are on the third page.
FINANCIAL AID CANNOT BE AWARDED UNTIL THE VERIFICATION PROCESS HAS BEEN COMPLETED.
Section A: Dependent Student’s Information
_______________________________________________________
___________________________
___________________________________________________________________
Street Address (includes apt. #)
_________________________________
Date of Birth
___________________________________________________________________
City
State
Zip Code
_________________________________
Email Address
___________________________________________________________________
Home Phone Number (include area code)
_________________________________
Cell Phone Number
Last Name
First Name
M. I.
Kutztown University Student’s ID or SSN
Section B: Household Information
Please indicate the number of parents living in the student’s household:
One parent
Two parents (includes stepparents and unmarried biological and/or adoptive parents)
Below, list the people in your parent’s household. Include:
•
•
•
Yourself and your parent(s), (including stepparent who lives with you and unmarried biological and/or adoptive parents,
do not include a non-custodial parent),
Your parents’ other children, only if (a) your parents will provide more than half of their support between July 1, 2014 and
June 30, 2015 or (b) the children would be required to provide parental information when applying for Federal Student Aid,
Other people if they now live with your parent(s), and only if your parents provide more than half of their support and will
continue to provide more than half of their support between July 1, 2014 and June 30, 2015.
Write the names of all household members in the space(s) below. Also, write in the name of the college for any household member,
excluding your parent(s), who will be attending college at least half-time between July 1, 2014 and June 30, 2015, and will be
enrolled in a program that leads to a college degree or certificate.
Full Name
Age
Relationship
College
Example: __________Mary Smith_____________________
____18____ ___________Sister_______________
____________XYZ University_________
__________________________________________________
___________ _______You, the student________
__________Kutztown University_______
__________________________________________________
___________
_______________________________
____________________________________
__________________________________________________
___________
_______________________________
___________________________________
__________________________________________________
___________
__ ____________________________
___________________________________
If you need more space, attach a separate sheet.
Page 1 of 5
DV5
Student Name: ______________________________
ID# or SSN: ________________________________
Section C: Tax Forms and Income Information (students and parent)
1.
TAX RETURN FILERS
Instructions: Complete this section if the student and/or parent(s) filed or will file a 2013 federal income tax return with the
IRS.
 The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If the student
and/or parent has not already used this tool, go to FAFSA.gov, log in to the student’s FAFSA record, select “Make FAFSA
Corrections,” and navigate to the Financial Information section of the form. From there, follow the instructions to
determine if the student and/or parent is eligible to use the IRS Data Retrieval Tool to transfer 2013 IRS income tax
information into the student’s FAFSA. It takes up to two weeks for IRS income information to be available for the IRS
Data Retrieval Tool, for electronic IRS tax return filers, and up to eight weeks for paper IRS tax return filers. If you need
more information about when, or how to use the IRS Data Retrieval Tool, contact Financial Aid Services at 610-6834077, email [email protected], or contact FAFSA at 1-800-433-3243.
If the student and/or parent are unable or chooses not to use the IRS Data Retrieval Tool, submit a 2013 IRS tax return
transcript(s) – we cannot accept a photocopy of the income tax return.
 To print a PDF copy of your IRS tax return transcript go to http://www.irs.gov/Individuals/Get-Transcript and click on
“Get Transcript ONLINE.” Click on the link to “Create an Account.” Once you enter your information, you will receive a
confirmation code in your email. Enter the code into the IRS website and click to verify. Once the code is verified, follow
the steps and answer the questions to proceed. You will be able to choose a reason for needing the transcript. If you
click on “Higher Education/Student Aid,” the screen changes to suggest that you get a tax return transcript. Select the
“2013 Return Transcript.” Print and send it to us.
 If you are not able to retrieve the transcript from the website, you will need to call the IRS at 1-800-908-9946. Make
sure that you are requesting the “IRS tax return transcript” and not the “IRS tax account transcript.” You will need your
Social Security Number, date of birth, and the address on file with the IRS (normally this will be the address used when
the 2013 IRS tax return was filed.) It takes up to two weeks for the IRS income information to be available for electronic
IRS tax return filers, and up to eight weeks for paper tax return filers.
Student’s
Parent’s IRS tax return transcript will be submitted to Financial Aid Services later.
Student
Parent filed or will file an extension for the 2013 tax year.
Student
Parent filed or will file an amended 2013 IRS tax return.
OR
OR
Verification cannot be completed until the IRS tax return transcript(s) has been submitted to Financial Aid Services.
2.
TAX RETURN NON-FILERS
Complete this section if the student and/or parent will not file and is not required to file a 2013 income tax return with the
IRS.
Check the box or boxes that apply:
A. I/We did not file and are not required to file a 2013 Federal Income tax return.
Student
Father/Stepfather
Mother/Stepmother
B.
If you or your parent did not file and are not required to file, list below you and/or your parent(s) employers, the
amount earned from each employer in 2013, and whether a W-2 form is attached. Please submit a copy of your W-2
forms to Financial Aid Services. If no income for 2013, put “0.” Do not leave blank.
Student’s.
Employer(s)
Amount(s)
W-2s Attached
Parent’s employer(s)
$ 1,280
Yes
Pro Auto
Amount(s)
W2s Attached
$
.00 _
$
$ 980
.00
$
.00 _
$
.00
$
.00 _
$
.00
_
_
$
.00 _
$
.00
_
ABC Shipping
Page 2 of 5
Yes
_
DV5
Student Name: ______________________________
ID# or SSN: ________________________________
Section C: Continued
1.
One of the persons listed in Section B of this worksheet received SNAP (Supplemental Nutrition Assistance Program)
benefits in 2012 or 2013.
Yes
2.
No
One of the person listed in Section B of this worksheet paid child support in 2013.
Yes
No
___________________________________________________
Signature of person who paid child support
Date
Name of Person Who Paid Child
Support
Name of Person to Whom Child
Support Was Paid
Name of Child for Whom
Support Was Paid
Ex: Joseph Jones
Jane Doe
Jacob Jones
Amount of Child Support Paid in
2013
$ 6,000
$
$
$
Total: $
.00
.00
.00
.00
If you need more space, attach a separate piece of page that includes the student’s name and social security number at the top.
Please enter amount received in 2013 or enter “0” if the answer is “none” for sections D and E. Do not leave any item blank.
Section D: 2013 Additional Financial Information:
Student
$____________ Taxable earnings from need-based employment programs, such as Federal Work-Study.
Parent
$____________
$____________ Combat pay or special combat pay; only enter the amount that was taxable.
$____________
Section E: 2013 Untaxed Income:
$____________ Child support received for all children. Don’t include foster 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 a basic military allowance for housing.
$____________
$____________ Veterans non education benefit – list benefit: ________________________________
$____________
$____________ Other untaxed income not reported above, such as workers’ compensations, disability, etc.
List source of untaxed income: _____________________________________________
$____________
$____________ Money received or paid on your behalf (e.g., bills), not reported elsewhere on this form.
Section F: High School Completion Status
In order for your financial aid to be disbursed, if you have not already done so, you are required to submit proof to the Kutztown
University Admissions Office that you have met high school graduation requirements. Submit one of the following:
 Official final high school transcript showing date of graduation which must be requested from the high school you
graduated from and arrive in a sealed envelope directly from the high school.
 Proof of successful completion of a GED.
 Homeschooled – if an official high school diploma is not awarded by an agency, homeschooled applicants must submit
the GED diploma and the scores from all five sections of the test. This information must be mailed directly from the
Department of Education issuing the diploma.
Page 3 of 5
Student Name: ______________________________
DV5
ID# or SSN: ________________________________
For sections G and I, student must appear either in person or sign in the presence of a Notary.
Only complete whichever option you choose.
Section G: Identity and Statement of Educational Purpose (TO BE SIGNED AT KUTZTOWN UNIVERSITY)
The student must appear in person at Kutztown University’s Financial Aid Office to verify his or her identity by presenting a valid
government-issued photo identification, such as, but not limited to, a driver’s license, other state-issued ID, or passport (A Kutztown
University ID is not acceptable.) Kutztown University will maintain a copy of the student’s government-issued photo ID notated with
the date it was received and the name of the official at the institution authorized to collect the student’s ID.
In addition, the student must sign, in the presence of the institution official, the following:
Statement of Educational Purpose
I certify that I _______________________________________am the individual signing this Statement of Educational
(Student Print Name)
Purpose and that the federal student financial assistance I may receive will only be used for educational purposes and to pay
the cost of attending Kutztown University for 2014-2015.
_______________________________________ __________
Student’s Signature
Date
_________ _________
FAO Initials
Date
Warning: If you purposefully give false or misleading information
Section H: Certification and Signatures
on this worksheet, you may be fined, be sentenced to jail, or both.
Each person signing this worksheet certifies that all of the information reported on it is complete and correct. The student and
one parent must sign and date this worksheet.
________________________________________________
Student’s Signature
__________________________________________
Date
________________________________________________
Parent’s Signature
__________________________________________
Date
If the student is unable to appear in person to Kutztown University, continue on to Section H and
complete Section I in the presence of a notary.
Page 4 of 5
Student Name: ______________________________
DV5
ID# or SSN: ________________________________
Section I: Identity and Statement of Purpose (TO BE SIGNED WITH NOTARY)
If the student is unable to appear in person at Kutztown University to verify his or her identity, the student must provide:
(a) A copy of the valid government-issued photo identification that is acknowledged in the notary statement below, such as but
not limited to a driver’s license, other state-issued ID, or passport; (A Kutztown University ID is not acceptable); and
(b) The original notarized Statement of Educational Purpose provided below.
Statement of Educational Purpose
I certify that I _______________________________________am the individual signing this Statement of Educational Purpose
(Student Print Name)
and that the federal student financial assistance I may receive will only be used for educational purposes and to pay the cost of
attending Kutztown University for 2014-2015.
___________________________________________
Student’s Signature
Date
Notary’s Certificate of Acknowledgement
State of ____________________________________________________________________________________
City/County of _______________________________________________________________________________
On ____________________________, before me, __________________________________________________
(Date)
(Notary’s Name)
personally appeared, _________________________________________________________, and provided to me
(Printed Name of Signer)
on basis of satisfactory evidence of identification ___________________________________________________
(Type of government-issued photo ID provided)
to be the above-named person who signed the forgoing instrument.
WITNESS my hand and official seal
________________________________________________
(seal)
My commission expires on _______________________
(Notary Signature)
(Date)
Please mail this form to:
Financial Aid Services, Kutztown University, P.O. Box 730, Kutztown, Pennsylvania, 19530
(Will not be accepted if faxed or emailed)
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