Barstow College 2009-2010 Independent Verification Worksheet Federal Student Aid Programs

Verification Worksheet
2700 Barstow Rd. Barstow, CA 92311
(760) 252-2411, x7205 Fax (760) 252-6748

Your FAFSA application has been selected for review in a process called “verification.” We are required by law to compare the information from your FAFSA application with the information provided on this form and with signed copies of your 2009 federal tax forms and your spouse’s or parents’ (if applicable). If there are differences between your FAFSA application and the documents you have submitted, corrections will be made.

We cannot process your financial aid until verification has been completed. Please provide required documents as soon as possible. Please print when filling out this form, complete all sections and sign the worksheet.

A. STUDENT INFORMATION


Last Name	First Name	M.I.	Social Security Number

Address (Include apt #)			Date of Birth

City	State	Zip Code	Phone Number (include area code)

Are you or will you be attending another college this year? Yes No
If yes, enter college’s name: ___________________________
What is your major: _________________________

B. DEPENDENCY STATUS

1.	What is your gender	Male	Female
2.	Were you born before January 1, 1987?	Yes	No
3.	As of today, are you married? (Answer "Yes" if you are separated but not divorced.)	Yes	No
4.	Do you have children who receive more than half of their support from you, or other dependents who live with you (other than your children and spouse) who receive more than half of their support from you, now and through June 30, 2011?	Yes	No
5.	Are you a veteran of the U.S. Armed Forces?	Yes	No
6.	Are you currently a member of the military? If yes, you must submit a current LES.	Yes	No
7.	At any time since you turned 13, were both of your parents deceased, were you in foster care, or were you a dependent or ward of the court?	Yes	No
8.	Are you or were you an emancipated minor as determined by a court in your state of legal residence?	Yes	No
9.	Are you or were you in legal guardianship as determined by a court in your state of legal residence?	Yes	No
10.	At any time on or after July 1, 2009, did your high school or school district homeless liaison determine that you were an unaccompanied youth who was homeless?	Yes	No
11.	At any time on or after July 1, 2009, did the director of an emergency shelter or transitional housing program funded by the U.S. Department of Housing and Urban Development determine that you were an unaccompanied youth who was homeless?	Yes	No
12.	At any time on or after July 1, 2009, did the director of a runaway or homeless youth basic center or transitional living program determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?	Yes	No
13.	Do you currently have a Bachelor's degree	Yes	No

C. PLEASE READ AND INITIAL THE STATEMENTS BELOW

I certify that the above information is true and correct. If this form has been completed with intent to receive federal financial aid on the basis of false and/or incomplete information, I understand that I am subject to denial of aid and possible federal prosecution. ______

Students receiving financial aid are expected to maintain satisfactory academic progress. Students must complete 67% of all classes attempted with a cumulative grade point average of 2.0 or above. _____

Students must complete educational goals prior to 150% of the published length of their selected program. Students working towards an Associate’s degree will be dismissed from financial aid after attempting 90 units. _____

Students who do not maintain satisfactory academic progress for two semesters will be dismissed from financial aid._____

Students receiving financial aid who withdraw from classes within the first 60% of the term or receive all F’s (IF’s or FW’s) or a combination of F’s and withdrawals/drops may be in repayment status for Title IV funds. _____

I understand that if I receive financial aid from more than one school during the same term I will be in overpayment status and may have to repay a portion or all of my grants. Furthermore, I understand that if I intend to transfer to another school during the 10–11 aid year and plan to receive financial aid at the other institution, I must notify the Barstow Community College Financial Aid Office of my intent._____

I understand that if for any reason I should become ineligible for financial aid, the fees that were paid by financial aid become a debt to the college that I must pay. ____

I understand that current charges for tuition and fees and minor charges (less than $100) will be deducted automatically from my financial aid check. ____

I authorize BCC to deduct from my financial aid check other outstanding charges I have incurred until I rescind
this statement in writing. Yes No

D. FAMILY INFORMATION

Independent Students: List the people in your household. Include: (1) Yourself, your spouse if married (2) your children, if you provide more than half of their support from July 1, 2010 through June 30, 2011; and (3) any other people if they now live with you, and you provided more than half of their support and will continue to provide more than half of their support from July 1, 2010 through June 30, 2011.

Write the names of all household members. Also write in the name of the college for any household member who will be attending college at least half time between July 1, 2010 and June 30, 2011, and will be enrolled in a degree diploma or certificate program. If you need more space, attach a separate piece of paper.

Dependent Students: List the people in your parents’ household. Include: (1) Yourself and your parent(s), including stepparent (these are the parents you are currently living with or would live with if you were not in school); (2) Your parents’ other children (even if they don’t live with your parents), if (a) your parents provide more than half of their support from July 1, 2010 through June 30, 2011, or (b) the children would be required to provide parental information when applying for Federal student aid; and (3) Other people if they now live with your parents, and your parents provide, and will continue to provide, more than half of their support from July 1, 2010 through June 30, 2011.

Write the names of all household members. Also write in the name of the college for any household member (excluding your parents), who will be attending college at least half time between July 1, 2010 and June 30, 2011, and will be enrolled in a degree diploma or certificate program. If you need more space, attach a separate piece of paper.

Full Name	Age	Relationship	College
Example: Martha Jones	24	Wife	City College
		Self	Barstow College

E. STUDENT AND SPOUSE/PARENT’S Additional Financial Information

Both tax filers and non-tax filers must list any untaxed income received and income adjustments in 2009. Be sure to enter zeros if no funds were received or adjusted. Failure to complete this section will delay the processing of your financial aid.

*Please report amounts received for the entire 2009 calendar year.

Student/Spouse	Calendar Year 2009	Parent(s)
$	Education credits (Hope and Lifetime Learning tax credits) from IRS Form 1040—line 49 or 1040A—line 31.	$
$	Child support paid because of divorce or separation or as a result of a legal requirement. Don’t include support for children in your household.	$
$	Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of fellowships and assistantships.	$
$	Student grant and scholarship aid reported to the IRS in your adjusted gross income. Includes AmeriCorps benefits (awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowships and assistantships.	$
$	Combat pay or special combat pay. Only enter the amount that was taxable and included in your adjusted gross income. Do not enter untaxed combat pay reported on the W-2 (Box 12, Code Q).	$
$	Earnings from work under a cooperative education program offered by a college.
$	Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including, but not limited to, amounts reported on the W-2 forms in Boxes 12a through 12d, codes D, E, F, G, H and S.	$
$	IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualified plans from IRS Form 1040—line 28 + line 32 or 1040A—line 17.	$
$	Child support received for all children. Don’t include foster care or adoption payments.	$
$	Tax exempt interest income from IRS Form 1040—line 8b or 1040A—line 8b.	$
$	Untaxed portions of IRA distributions from IRS Form 1040—lines (15a minus 15b) or 1040A—lines (11a minus 11b). Exclude rollovers. If negative, enter a zero here.	$
$	Untaxed portions of pensions from IRS Form 1040—lines (16a minus 16b) or 1040A—lines (12a minus 12b). Exclude rollovers. If negative, enter a zero here.	$
$	Housing, food and other living allowances paid to members of the military, clergy and others (including cash payments and cash value of benefits). Don't include the value of on-base military housing or the value of basic military allowance for housing.	$
$	Veterans non-education benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.	$
$	Other untaxed income not reported, such as workers’ compensation, disability, etc. Don’t 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 paid on your behalf (e.g., bills), not reported elsewhere on this form.	$

F. STUDENT’S/SPOUSE TAX FORMS AND INCOME INFORMATION______________________

1. Check only one box below. Tax returns include the 2009 IRS form 1040, 1040A, 1040EZ, a tax return from Puerto Rico or a foreign income tax return. If you did not keep a copy of your tax return, request a copy from your tax preparer or request a tax return transcript from the IRS at 1-800-829-1040

Check here if you are attaching a signed copy of your federal tax return.

Check here if you will not file and are not required to file a 2009 U.S. Income Tax Return.

2. If you did not file and are not required to file a 2009 Federal income tax return, list below your employer(s) and any income received in 2009 (use the W-2 form or other earnings statements if available).

List below all of the sources and amounts of money received from January 1, 2009 through December 31, 2009. Include untaxed income (e.g., CalWORKs, SSI, disability income) and earnings or income not reported on a federal state income tax return (e.g., unemployment insurance income if tax return not filed).

Source of Money	Annual Amount January 2009-December 2009
	$
	$
	$
Total	$

G. PARENT(S)’ TAX FORMS AND INCOME INFORMATION_______________________________

1. Check only one box below. Tax returns include the 2009 IRS Form 1040, 1040EZ, a tax return from Puerto Rico or a foreign income tax return. If you r parent(s) did not keep a copy of their tax return, request a copy from the tax preparer or request a tax return transcript from the IRS at 1-800-829-1040.

Check here if you are attaching a signed copy of your federal tax return.

Check here if you will not file and are not required to file a 2009 U.S. Income Tax Return.

2. If your parent(s) did not file and are not required to file a 2009 Federal income tax return, list below your parent(s)’ employer(s) and any income they received in 2009 (use the W-2 form or other earning statements if available).

List below all of the sources and amounts of money your parent’s received from January 1, 2009 through December 31, 2009. Include untaxed income (e.g., CalWORKs, SSI, disability income) and earning or income not reported on a federal or state income tax return (e.g., unemployment insurance income if tax return not filed).

Source of Money	Annual Amount January 2009-December 2009
	$
	$
	$
Total	$

F. SIGNATURES

By signing, I (we) certify that all information reported on this worksheet is complete and correct. At least one parent (if student is dependent) must also sign. Warning: If you purposely give false or misleading information on this worksheet, you may be fined, sentenced to jail, or both.

Student Signature		Date
Parent Signature (if applicable)		Date