VERIFIATION WORKSHEET 2017 2018 Henderson …

1 Henderson State university Office of Financial Aid Womack Hall Room 203A HSU Box 7812 Arkadelphia, AR 71999-0001 FAX /financialaid VERIFICATION WORKSHEET 2017 - 2018 (Dependent Student) Your 2017 - 2018 Free Application for Federal Student Aid (FAFSA) has been selected for Verification Review. The law states we must compare the information on this WORKSHEET and any other required documents with the information on your FAFSA. If there are differences, we will correct your FAFSA. You and a parent reported on your FAFSA must complete, sign and submit this form and all other required documents to the Financial Aid Office at Henderson State university .

2 We may request additional information . STUDENT S information _____ _____ Student s Last Name Student s First Name Student s MI Student s Social Security Number _____ _____ Student s Street Address (include apt. no.) Student s Date of Birth _____ _____ City State Zip Code Student s Email Address _____ _____ Student s Home Phone Number (include area code) Student s Cell Phone Number HOUSEHOLD SIZE AND NUMBER IN COLLEGE List the people for whom your parents will provide over half the support between July 1, 2017 and June 30, 2018 .

3 FULL NAME: Include yourself, your custodial parents (including stepparent), your parents dependent children, and other people ONLY if they live with your parents and receive over half their support from your parents. AGE RELATIONSHIP COLLEGE Will be Enrolled at least Half Time (Yes or No) 1. Student s Name: Self Henderson State university 2. 3. 4. 5. 6. 7. 8. 9. 10. Student s Name_____ Student s SSN _____ Check all boxes that apply for Non-tax Filers: I was not employed and had no income earned from work in 2015. Neither parent was employed, and neither had income earned from work in 2015.

4 The student and/or one or both parents were employed in 2015, and have listed below the names of all employers, the amount earned from each employer in 2015, and whether an IRS W-2 form is provided. [Provide copies of all 2015 IRS W-2 forms issued by your employers]. List every employer even if the employer did not issue an IRS W-2 form. If more space is needed, provide a separate page with the student s name and ID number at the top. Provide documentation from the IRS dated on or after October 1, 2016 that indicates a 2015 IRS income tax return was not filed with the IRS. ____ Check here if confirmation of non-filing provided.

5 ____ Check here if confirmation of non-filing will be provided later. Complete this section if the student and/or parent filed or will file a 2015 IRS income tax return. Check all boxes that apply: The student has used the IRS DRT in FAFSA on the Web to transfer 2015 IRS income tax return information into the student s FAFSA. The parents have used the IRS DRT in FAFSA on the Web to transfer 2015 IRS income tax return information into the student s FAFSA. The student is unable or chooses not to use the IRS DRT in FAFSA on the Web, and instead will provide the school with a 2015 IRS Tax Return Transcript(s) and a signed copy of the 2015 Amended Tax Return, if filed.

6 The parents are unable or chooses not to use the IRS DRT in FAFSA on the Web, and instead will provide the school with a 2015 IRS Tax Return Transcript(s) and a signed copy of the 2015 Amended Tax Return, if filed. To obtain your Tax Return Transcript , go to and click on Get a Tax Transcript . You may request the transcript be mailed to your address on record in 5 to 10 calendar days. If parents filed separate 2015 IRS income tax returns, the IRS DRT cannot be used. The 2015 IRS Tax Return Tran-script(s) must be provided for each. ____ Check here if 2015 IRS Tax Return Transcript(s) is provided.

7 Each person signing below certifies that all information reported is complete and correct. _____ Student Signature (Required) Date _____ Parent s Signature (Required) Date WARNING: If you purposely give false or misleading information you may be fined, be sentenced to jail, or both. (Reference: Higher Education Act, as amended October 2002, Section 490. [20 1097]) Employer s Name IRS W-2 Provided? Annual Amount Earned in 2015 Total Amount of Income Earned From Work $