Page 1 of 2 DEP Financial Aid Services 243 Whitmore Administration Building 181 Presidents Drive, Amherst, MA 01003 Phone: 413-545-0801 Web: umass.edu/umfa Fax: 413-545-1700 Email: ﬁnaid@ﬁnaid.umass.edu 2015-2016 Veriﬁcation of Additional Household Resources PART I: STUDENT INFORMATION Name:_______________________________________________________________________________________ SPIRE ID:____________________________ Last First Middle Home Address:______________________________________________________________________________________________________________________ # Street City Date of Birth: _________/_______/_____________ State Phone Number: ( Zip ) _________ - _______________ PART II: HOUSEHOLD RESOURCES INFORMATION Please report below any amount received in 2014 by you and your parent(s). Report total amount received for the entire year. Do not include student ﬁnancial aid received. You must check yes or no for each question in order for the form be considered complete. Did you or your parent(s)... ...Receive money or have bills paid by someone not in the household? Parent(s) •Yes Amount $________ Student • No •Yes Amount $________ • No ...Receive income or beneﬁts from the government/state in any of the following forms? ● Social Security Beneﬁts •Yes Amount $_______ • No •Yes Amount $________ • No ● Worker’s Compensation •Yes Amount $________ • No •Yes Amount $________ • No ● TAFDC or EAEDC •Yes Amount $________ • No •Yes Amount $________ • No ● Fuel, Heat, or Energy Assistance •Yes Amount $________ • No •Yes Amount $________ • No ● SNAP or WIC •Yes Amount $________ • No •Yes Amount $________ • No ● Section 8, MRVP, or AHVP •Yes Amount $________ • No •Yes Amount $________ • No ● Railroad Retirement Beneﬁts •Yes Amount $________ • No •Yes Amount $________ • No ● Black Lung Beneﬁts •Yes Amount $________ • No •Yes Amount $________ • No ...Receive cash payment for food, housing, or living expenses as a member of the military or clergy? •Yes Amount $________ • No •Yes Amount $________ • No ...Receive alimony? •Yes Amount $________ • No •Yes Amount $________ • No ...Receive child support? •Yes Amount $________ • No •Yes Amount $________ • No ...Receive tax-exempt interest income? •Yes Amount $________ • No •Yes Amount $________ • No ...Receive foreign income? •Yes Amount $________ • No •Yes Amount $________ • No ...Receive any other forms of income? if yes, explain: ____________________________________________ •Yes Amount $________ • No •Yes Amount $________ • No ...Make withdrawals from an IRA, pension, or other retirement account? •Yes Amount $________ • No •Yes Amount $________ • No ...Pay into a health saving account? •Yes Amount $________ • No •Yes Amount $________ • No *FDRESE* Page 2 of 2 DEP Name:_________________________________________________________________ SPIRE ID:___________________________ If your total annual household income falls below the following 2014 Federal Poverty Guidelines, please provide a detailed explanation of how the family was supported during the 2014 year in the box below. # of People 1 2 3 4 5 6 7 8 Each additional 100% FPL $11,676 $15,732 $19,800 $23,856 $27,912 $31,980 $36,036 $40,092 +$4,068 Explan how the family met all ﬁnancial obligations in 2014 (rent/mortgage, food, heat, health insurance,taxes,etc.): PART III: CERTIFICATION Any ﬁnancial aid awarded prior to veriﬁcation is tentative. Financial Aid Services has the right, after reviewing your veriﬁcation information, to change or cancel your award. Changes in funding, administrative/technical errors, changes in application information, enrollment status or reclassiﬁcation in residency will affect your ﬁnancial aid award and may result in a revised ﬁnancial aid award. By my signature, I certify that all information submitted with and written on this application is complete, accurate, and corrections may be made based on data provided, and that if I purposely give false or misleading information on this worksheet, I may be ﬁned, sentenced to prison, or both. I also certify that any federal or state ﬁnancial aid funds I may receive will only be used to pay for educational expenses related to my attendance at the University of Massachusetts Amherst for 2015-2016. ____________________________________________________________________________ Please be aware Financial Aid Services is obligated Student Signature Date Parent Signature Date to report ﬁnancial aid applicants that purposely misreported information or altered documentation to obtain federal funds to the Ofﬁce of Inpector ____________________________________________________________________________ General for investigation and prosecution. Document must be signed with a real signature. Digital signatures are not accepted. Fax completed, signed form to: 413-545-1700 or email completed, signed form to: fadocs@ﬁnaid.umass.edu (Attachments must be a standard image ﬁle, or in one of the following ﬁle formats: .doc, .docx, .pdf) *FDRESE*