2014–2015 Dependent Verification Worksheet

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PimaCommunityCollege
2014–2015 Dependent Verification Worksheet
You have been selected for verification, which means that you must submit this completed Verification Worksheet with any additional documentation listed on
your MyPima Financial Aid tab and/or in section C of this form according to your tax filing status. If the Financial Aid office encounters discrepant information
in your file you may be required to submit additional documentation. The preferred way to supply tax information is through the IRS Data Retrieval Tool which
links your IRS information to your FAFSA. You may use this tool at the time of completing your FAFSA, or you may use it now by logging into your FAFSA
(www.fafsa.ed.gov), selecting the IRS Data Retrieval Tool under the “Financial Information” tab, and re-submitting your FAFSA after the retrieval is complete.
If you cannot, or choose not to use the tool, attach yours and your parent(s)’ 2013 IRS tax return transcripts and copies of all 2013 W-2 forms. If your
parent(s) were not required to file a tax return, they will need to provide their 2013 IRS verification of non-filing status, and copies of all 2013 W-2 forms for
income earned from work. You can order tax transcripts and verifications of non-filing at www.irs.gov or by calling the IRS automated line at 1-800-908-9946.
If you are unable to use the automated line for any reason, call the IRS at 1-800-829-1040.
YOU MUST COMPLETE ALL BLANKS ON THIS FORM OR IT WILL NOT BE PROCESSED
Write “0” or “NA” for items that do not apply to you
A. Student Information
A_______________________________
______________________________________________________________________
Last Name
First Name
M.I.
Student ID Number
_____________________
Date of birth
B. Family Information
1.
List below ALL the people in your parent(s)’ household who meet the following criteria, including:
 Yourself and your parent(s) (including a stepparent) even if you don’t live with your parent(s).
 Your parent(s)’ other children if your parent(s) will provide MORE than half of their support from July 1, 2014, through June 30, 2015, or if the other
children would be required to provide parental information if they were completing a FAFSA for 2014–2015. Include children who meet either of
these standards, even if they do not live with your parent(s).
 Other people if they now live with your parent(s) and your parent(s) provide MORE than half of their support and will continue to provide more than
half of their support through June 30, 2015.
2.
For those household members who will also be attending college, include the name of the college and whether or not that person will be enrolled at least
half time in a degree, diploma, or certificate program at a postsecondary education institution any time between July 1, 2014 and June 30, 2015.
Full Name
Missy Jones (example)
Age
Relationship
18
Sister
Self
If Attending College Currently,
Enter Name of School
Not attending college
Pima Community College
State Where
College is Located
NA
AZ
Will be Enrolled at
Least Half Time
No
If more space is needed, attach a separate page with the student’s name and student ID number at the top.
C. IRS Tax Transcripts and W2 Form(s)

I have used the IRS Data Retrieval Tool and, according to
MyPima, I am not required to submit additional tax documents.

My parent(s) have used the IRS Data Retrieval Tool and, according to
MyPima, they are not required to submit additional tax documents.

I am attaching a copy of my 2013 IRS tax transcript AND
copies of all my 2013 W-2 form(s).

I am attaching a copy of my parent(s)’ 2013 IRS tax transcript AND
copies of all my parent(s)’ 2013 W-2 form(s).

I did not and was not required to file taxes in 2013 so I am
attaching copies of my W-2(s) for any wages earned in 2013.

My parent(s) did not and were not required to file taxes in 2013 so I
am attaching a copy of their IRS verification of non-filing status,
and 2013 W-2(s) for any wages earned.
______________________________________________________________________
Last Name
First Name
M.I.
A________________________________
__________________
Date of Birth
Student ID Number
YOU MUST COMPLETE ALL BLANKS ON THIS FORM OR IT WILL NOT BE PROCESSED
Write “0” or “NA” for items that do not apply to you
D. Federal Benefits for 2012 and/or 2013
Select all Federal benefits received at any point in 2012 and/or 2013 by you OR your parent(s) OR anyone your parent(s) will support financially more than
50% between 7/1/14 to 6/30/15.
Received in 2012 and/or 2013
Federal Benefits
1.
2.
3.
4.
5.
Parent(s) or other individual
in parent(s)’ household





SSI or SSDI
SNAP (Food Stamps)
Free or Reduced Lunch
TANF (Welfare)
WIC
Student





E. Student and Parent(s)’ Child Support PAID and Asset Information
1.
List the total ANNUAL amount of child support you AND/OR your parent(s) PAID in 2013 due to divorce, separation, or legal requirement (attach
separate page if needed). Include only children who are not living in your parent(s)’ household under Section B of this form.
Paid by (select one)
Student
Parent
Student
Parent
Student
Parent
2.
Child’s Name (not listed on Section B)
Name of Person You or Your Parent Paid
$
$
$
Total Amount for 2013
Report the net worth of the assets listed below that you and your parent(s) own. Place zeroes in the spaces of any assets that you do not own. The
net worth of an asset is calculated by first determining the current value and then subtracting any outstanding debt. Note: Only report the net
worth of the share that is owned by you or your parent(s).
Asset Verification Items
Cash, Savings and/or Checking Account Balance
Investments (property other than the home you or parent(s) live in, trust funds, CD, stocks, etc.)
Business/Farms (only report if business employs more than 100 full-time employees)
$
$
$
Parent Net Amount
Student Net Amount
$
$
$
F. Additional Income from Work
List any other income earned in 2013 by you and/or your parent(s) from employment that is NOT listed on a W-2 or on your tax return. If you do not have
additional income to report in this section, you must enter zero or NA in the chart. If your parent(s) were not required to file a tax return you will also need to
attach a copy of their IRS verification of non-filing status, which can be obtained at www.irs.gov.
Name of Employer
(individual or company)
Description of Job
1.
2.
3.
4.
Total Amount
Earned in 2013
$
$
$
$
Earned by
(select one)
STUDENT
STUDENT
STUDENT
STUDENT
PARENT
PARENT
PARENT
PARENT
G. Certification
The student and parent must hand-sign and date this form certifying all the information reported is complete and correct. If you purposely give false or
misleading information, you may be fined $20,000, sent to prison, or both.
Student Signature (handwritten)
Student Service Center Staff Use Only:
Date Received
Staff Name
Date
Parent Signature (handwritten)
Date
Scan and email to [email protected] or
Submit to any campus Student Services Center
Pima Community College is an equal opportunity, affirmative action employer and educational institution committed to excellence through diversity. Reasonable accommodations, including materials in an alternative
format, will be made for individuals with disabilities when a minimum of five working days advance notice is given. For the general public, please contact the PCC information line at 206-4500 (TTY 206-4530); for PCC
students, contact the appropriate campus Disabled Student Resources Office.