2011-2012 Verification Worksheet Independent Student Your application was selected by the U.S. Department of Education for review in a process called “verification.” In this process, we are required by federal law (34 CFR, Part 668) to compare your FAFSA information with information provided on this form, and with signed copies of your and your spouse’s 2010 federal tax forms. If there are differences between your application and the documents you’ve submitted, corrections may need to be made. We cannot process your financial aid until this completed worksheet, signed copies of tax forms and other relevant documents are submitted to our office.
A. Student Information ___________________________________________________ Last Name First Name M.I.
______________________________________________ Social Security Number
___________________________________________________ Address (include apt. no.)
______________________________________________ Date of Birth
___________________________________________________ City State ZIP Code
______________________________________________ Student E-mail Address
___________________________________________________ Home Phone Number
______________________________________________ Student Cell Phone Number
B. Family Information List the people in your household that you, and your spouse (if you have one), will support between July 1, 2011 and June 30, 2012. Include: • Yourself • Your spouse • Your children (if they receive more than 50% of their financial support from you) • Other people who live with and receive more than 50% of their financial support from you and will continue to through June 30, 2012 Name
1.
Age
Relationship to Student
College student will attend in 2011-2012
Self
Emmanuel College
2011-2012 Enrollment: Full-Time, Half-Time, Less Than Half-Time
Undergrad/ Grad
2. 3. 4. 5. 6. 7. Office of Student Financial Services, Emmanuel College, 400 The Fenway, Boston, MA 02115 Phone: 617-735-9938 Fax: 617-735-9939 E-mail: financialservices@emmanuel.edu Office Use Only: FCVIN11
C. Student Federal Tax Information All students must check one:
Attached is my signed 2010 Federal Income Tax Return (IRS Form 1040, 1040A, 1040EZ). If you did not keep a copy of your tax return, request a copy from your tax preparer or a “tax return transcript” from the IRS (1-800829-1040) I will not file and am not required to file a 2010 Federal Income Tax Return. Please report 2010 earnings below: Employer/Source of Income ________________________ ________________________
Amount Received for 2010 $ ____________________ $ ____________________
D. Student Untaxed Income and Benefits Report below all untaxed income that you and your spouse received during the 2010 calendar year; be sure to enter annual amounts and enter zeros if no funds were received.
Student $
2010 Calendar Year Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including, but not limited to, amounts reported on W-2 Forms in Boxes 12a through 12d, codes D, E, F, G, H and S.
$
Child support received and/or other monetary support received for all children. Do not include foster care 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).
$
Veterans non-education benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC), etc.
$
Other untaxed income not reported, such as workers’ compensation, disability, etc. Also include the first-time homebuyer tax credit from IRS Form 1040-line 67. Do not include student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act educational benefits, on-base military housing or a military housing allowance, combat pay (if you are not a tax filer), benefits from flexible spending arrangements (e.g., cafeteria plans), foreign income exclusion or credit for federal tax on special fuels.
$
Money received, or any money paid on your behalf, not reported elsewhere on this form.
E. Signatures By signing this worksheet, I certify that all the information reported on this worksheet is complete and correct. If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. NOTE: Only complete applications will be processed. Please review this application to ensure that either an amount or a “0” (zero) has been entered where designated.
Student’s Signature: _______________________________________
Date: __________________________
Office of Student Financial Services, Emmanuel College, 400 The Fenway, Boston, MA 02115 Phone: 617-735-9938 Fax: 617-735-9939 E-mail: financialservices@emmanuel.edu