2014-2015 Verification Worksheet – V5
Your application was selected by the Department of Education for review in a process called “Verification.” In this process, we are
required to verify the accuracy of the information from your 2014-2015 FAFSA. Complete this form and submit it along with any
other relevant documentation to the Financial Aid Office. (Warning: If you purposely give false or misleading information on this
worksheet, you may be fined, sentenced to jail or both).
A. Student Information
____________________________________________ ________________________ ______________
Last Name
First Name
MI
Social Security Number
Date of Birth
___________________________________________ __________________ ________ ______________________________
Street Address
City/State
Zip
Telephone
_____________________________________________________
__________________________________
Email Address
Student ID
B. Family Information
Using the dates of July 1, 2014 through June 30, 2015, please complete the section below.
Dependent Students – List ALL the People in Your Household
Yourself and your parents (including stepparents, legal or biological parents), even if you don’t live with your parents and
even if your parents are not married but living in the same household
 Your parents other children if your parents will provide more than half of their support, of if the other children would be
required to provide parental information if they were completing a FAFSA; include children who meet either of these
standards even if the children do not live with the parents
 Other people if they live with your parents are your parents provide and will continue to provide more than half of their
support
Independent Students – List ALL the People in Your Household
 You and your spouse, if you have one
 Your and your spouse’s children if you or your spouse will provide more than half of their support, even if the children do
not live with you
 Other people of they live with you and either you or your spouse provide and will continue to provide more than half of
their support
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 in a program that leads to a college degree or certificate. If more space is needed, attach a separate page with the
student’s name and student ID number at the top.

Full Name
C. Receipt of SNAP Benefits
Age
Relationship
Self (Student)
College
RSU
Did a member of your household receive SNAP benefits (formerly known as the Food Stamp Program) sometime during 2012 or
2013? _____ Yes
_____No
(If yes, attach supporting documentation/Statement of Benefits)
Name__________________________________________________________ Student ID_________________ V5 Page 2
D. Income Information
Dependent Student (check correct boxes only)
Independent Student (check correct box only)
Did you work?
Did or will you file 2013 taxes?
Did you use IRS Data Retrieval?
Did your parent(s) work?
Did or will your parent(s) file 2013 taxes?
Did your parent(s) use IRS Data Retrieval?
Did you work?
Did or will you file 2013 taxes?
Did you use IRS Data Retrieval?
Did your spouse work?
Did or will your spouse file 2013 taxes?
Did your spouse use IRS Data Retrieval?
_____ Yes
_____ Yes
_____ Yes
_____ Yes
_____ Yes
_____ Yes
_____ No
_____ No
_____ No
_____ No
_____ No
_____ No
Did your parent’s file joint taxes?
_____ Yes _____ No
If you or your parents(s) filed taxes and did not use the IRS Data
Retrieval, attach your 2013 IRS Tax Return Transcript(s) to this form.
_____ Yes
_____ Yes
_____ Yes
_____ Yes
_____ Yes
_____ Yes
_____ No
_____ No
_____ No
_____ No
_____ No
_____ No
Did you and your spouse file joint taxes? _____ Yes _____ No
If you filed taxes and did not use the IRS Data Retrieval, attach a
copy of your 2013 IRS Tax Return Transcript(s) to this form.
E. Fill out this section only if you DID NOT file 2013 taxes
If you and/or your parent(s) earned income by working in 2013 and did not file a 2013 tax return, list yours and your parent(s)
employer names and amount earned. Attach copies of your and your parents 2013 W-2’s. If neither you nor your parent(s) earned
income by working, attach a written statement explaining the means and amounts of 2013 financial support for the people listed
in the household.
Student’s Employer Names
Amount Earned
$
$
$
$
Parent’s Employer Names
Amount Earned
$
$
$
$
F. Other Income Information
Please report ANNUAL amounts for 2013. If an item does not apply to you or your parent(s), please write “NA” for amounts.
Student Amount
Parent(s) Amount
IRA Deductions and Payments to SEP, SIMPLE, Keogh, etc
Tax exempt Interest Income
$
$
$
$
Untaxed IRA distributions (exclude rollovers)
Untaxed portions of pensions and annuities (exclude rollovers)
$
$
$
$
G. Child Support Paid
Please report ANNUAL amounts for 2013. If an item does not apply to you, your parent or your spouse, please write “NA” for
amounts.
Name of Person Who
Paid Child Support
Name of Person to Whom
Child Support was Paid
Name of Child for Whom
Support was Paid
Amount of Child
Support Paid in 2013
$
$
$
$
H. High School Completion Status
Provide one of the following documents that indicate your high school completion status:
High School Diploma - high school diploma or high school transcript that shows the date you completed high school
Recognized Equivalent of a High School Diploma - A copy of your GED
Homeschool - If your state law requires a homeschooled student to obtain a secondary school completion credential for
homeschool (other than a high school diploma or it’s recognized equivalent), a copy of that credential).
I. Certification and Signature. The person(s) signing below certifies that all of the information reported on this form is
complete and accurate.
___________________________________________________________ __________________________________________________________
Student Signature
Date
Parent Signature (dependent students only)
Date
Name___________________________________ _____________________ Student ID___________________ V5 Page 3
J. Identity and Statement of Educational Purpose
Student must complete Option 1 or Option 2.
Option 1 - To Be Signed at Rogers State University
The student must appear in person at Rogers State University to verify his or her identity by presenting a valid
government-issued photo identification (ID), such as, but not limited to, a driver’s license, other state-issued ID, or
passport. The institution will maintain a copy of the student’s photo ID that is annotated by the institution with the date
it was received and reviewed 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 institutional official, the following Statement:
Statement of Educational Purpose
I certify that I ______________________________________ am the individual signing this
(Print Your Name)
Statement of Educational 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 Rogers State University
for 2014-2015.
_________________________________________ _______________ ________________
Student’s Signature
Date
Student ID
Proper ID received by RSU Financial Aid Office Signature__________________________________ Date_____________
Option 2 - To Be Signed With Notary
If the student is unable to appear in person at Rogers State University to verify his or her identity, the student must
provide:
(a) A copy of the valid government-issued photo identification (ID) that is acknowledged in the notary statement below,
such as, but not limited to a driver’s license, other state-issued ID, or passport; and
(b) The original notarized Statement of Educational Purpose (in English or Spanish) provided
below.
Statement of Educational Purpose
I certify that I ________________________________________ am the individual signing this
(Print Your Name)
Statement of Educational 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 Rogers State University
for 2014-2015.
_________________________________________ _______________ _________________
Student’s Signature
Date
Student ID
Notary’s Certificate of Acknowledgement
State of _____________________________________________________________________
City/County of ________________________________________________________________
On_____________________, before me, __________________________________________,
(Date)
(Notary’s name)
personally appeared, __________________________________________, and proved 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 foregoing instrument.
WITNESS my hand and official seal
____________________________________________________
(Notary signature)
My commission expires on _________________________ (Date)
(seal)