2016-2017 Dependent Verification Form Financial Aid Office Name

Name: _______________________________________________
Last
First
MI
Financial Aid Office
Student ID# __________________________________________
1000 East Victoria Street
Carson, CA 90747
(310) 243-3691 · Fax (310) 516-4498
2016-2017 Dependent Verification Form
Your 2016-2017 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called
verification. Under federal regulations, some students are asked to validate the information provided on the FAFSA to
assure that the information provided is accurate. We will compare your FAFSA with the information on this form and with
any other required documents. If there are differences, your FAFSA information may need to be corrected. You and at least
one parent must complete and sign this form, attach any required documents, and submit the form and other required
documents to the Financial Aid Office.
Check the appropriate box for your Parents:
 FAFSA Marital Status is “Married” and my parents’ tax filing status was “Married Filing Jointly.” You must attach a
copy of your parents’ 2015 IRS Tax Return Transcript, if you did not use the IRS Data Retrieval tool, AND copies of
all 2015 W-2’s
 FAFSA Marital Status is “Married,” and my parents’ tax filing status was “Married Filing Separately.” You must
attach a copy of BOTH parents’ 2015 IRS Tax Return Transcripts AND copies of all 2015 W-2’s.
 FAFSA Marital Status is “Unmarried”– both parents living together. You must attach a copy of BOTH parents 2015
IRS Tax Return Transcripts AND copies of all 2015 W-2’s.
 The tax filing status was “Married Filing Jointly;” however my parents have since Separated, Divorced, or have been
Widowed. You must attach a copy of BOTH parents 2015 IRS Tax Return Transcript AND copies of all 2015 W-2’s.
 None of the above apply.
A. DEPENDENT STUDENT’S FAMILY INFORMATION
List the people in your parent(s) household. Include:
■ Yourself
■ Your parent(s) (including a stepparent if parent is remarried) even if you don’t live with your parent(s)
■ Your parent(s) other children as long as your parent(s) will provide more than half of their support from July 1, 2016
- June 30, 2017 or if the other children would be required to provide parental information if they were completing a
FAFSA for 2016–2017. Include children who meet either of these standards, even if they do not live with your
parent(s).
Full Name
Age
Relationship
Self
College
Will be Enrolled
at Least Half
Time (Yes/No)
CSU Dominguez Hills
Note: We may require additional documentation if we have reason to believe that the information regarding the
household member enrolled in eligible postsecondary educational institutions is inaccurate.
If more space is needed, attach a separate page with your name and Student ID Number at the top.
Student’s Name: ____________________________
Student ID#__________________________________
B. DEPENDENT STUDENT’S INCOME INFORMATION TO BE VERIFIED
(Complete only one option in this section)
1.
TAX RETURN FILERS: Complete this section if you filed a 2015 income tax return with the IRS. The best way
to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web.
Check the box that applies:
 I used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2015 IRS income information into my
FAFSA. I have attached copies of all of my 2015 W-2’s.
 I have attached copies of my 2015 IRS tax return transcript and all of my 2015 W-2’s to this form. You may
request a FREE of charge transcript of the 2015 federal tax return from the IRS in one of the following ways:
 Online at www.irs.gov – Under TOOLS, select “Get a Tax Transcript.” Then select “Get Transcript by
MAIL.”
 By calling 1-800-908-9946 – Follow the prompts
 By mail using the IRS Form 4506T-EZ
2.
AMENDED TAX RETURN FILERS: If you changed or corrected your original federal income tax return filed
with the IRS, you must submit:
 2015 IRS Tax Return Transcript;
 A complete and signed copy of your 2015 Form 1040X, with all schedules attached; AND
 Copies of all 2015 W-2’s
3.
NON-TAX FILERS: Complete this section if you will not file and you are not required to file a 2015 income tax
return with the IRS. Check the box that applies:
 I was not employed and had no income earned from work in 2015. Please list below how you met your basic
living expenses (food, housing, etc.). Include the dollar amount and source of any support (e.g. monetary
support from others, Veteran’s Benefits, Financial Aid refunds, etc.).
Type of Assistance

2015 Amount Received
I was employed in 2015 and have listed below the names of all employers, the amount(s) earned from each
employer in 2015, and have attached copies of all 2015 IRS W-2 form(s). List all employers even if they did
not issue a 2015 IRS W-2 form. If more space is needed, attach a separate page listing your name and Student
ID Number at the top.
Employer’s Name
2015 Amount Earned
C. PARENT’S INCOME INFORMATION TO BE VERIFIED (Complete only one option in this section)
If two parents (married or unmarried and both parents are living together) were reported in Section A of this form, the
instructions and certifications below apply to both parents.
1.
TAX RETURN FILERS: Complete this section if your parent(s) filed a 2015 income tax return with the IRS.
The best way to verify income is by using the IRS Data Retrieval Tool that is part of FAFSA on the Web. If your
parents filed separate 2015 IRS income tax returns, you must provide copies of both parent’s 2015 IRS Tax Return
Transcripts. Check the box that applies:
 My parent(s) used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2015 IRS income
information. I have attached copies of all of my parents’ 2015 W-2’s.
 My parent(s) 2015 IRS tax return transcript(s) and copies of all 2015 W-2’s are attached to this form. You
may request a FREE of charge transcript of the 2015 federal tax return from the IRS in one of the following
ways:
 Online at www.irs.gov – Under TOOLS, select “Get a Tax Transcript.” Then Select “Get Transcript by
MAIL.”
 By calling 1-800-908-9946 – Follow the prompts
 By mail using the IRS Form 4506T-EZ
Student’s Name: ____________________________
Student ID#__________________________________
2.
AMENDED TAX RETURN FILERS: If your parents changed or corrected their original federal income tax
return filed with the IRS, you must submit:
 A copy of their 2015 IRS Tax Return Transcript;
 A complete and signed copy of 2015 Form 1040X, with all schedules attached; AND
 Copies of all 2015 W-2’s.
3.
NON-TAX FILERS: Complete this section if your parents are not required to file a 2015 income tax return with
the IRS. Check the box that applies:
 Neither of my parent(s) were employed and had no income earned from work in 2015. Please explain below
how your parents were able to meet the family’s basic living expenses (food, housing, etc.). Include the dollar
amount and the source of any support (e.g. monetary support from others, Veteran’s Benefits, TANF, etc.).
Type of Assistance

2015 Amount Received
One or both of my parent(s) was employed in 2015. Listed below are the names of my parent’s employers,
the amount earned from each employer in 2015. Attached are copies of all 2015 IRS W-2 forms issued to my
parent(s) by employer(s). List every employer even if they did not issue a 2015 IRS W-2 form. If more space
is needed, attach a separate page with the student’s name and Student ID Number at the top.
Employer’s Name
2015 Amount Earned
D. PARENT’S OTHER INFORMATION TO BE VERIFIED

Check this box if someone in your parent’s household (listed in Section A) received benefits from the
Supplemental Nutrition Assistance Program or SNAP (formerly known as food stamps) any time during the
2014 or 2015 calendar years.
 I have attached required documentation to this form which shows receipt of SNAP benefits.
E. COMPLETE THIS SECTION IF ONE OF THE STUDENT’S PARENTS PAID CHILD SUPPORT
IN 2015.
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
2015
Note: If we have reason to believe that the information regarding child support paid is not accurate, we may require
additional documentation.
F. CERTIFICATION AND SIGNATURE
Each person signing below certifies that all of the
information reported is complete and correct.
WARNING: If you purposely give false or
misleading information you may be fined,
be sentenced to jail, or both.
_______________________________________________
Student’s Signature (Required)
_______________________________________
Date
________________________________________________
Parent’s Signature (Required)
_______________________________________
Date