Student Banner ID____________________
2011-2012 Independent Verification Form
Your application has been selected for verification; therefore, you and your spouse, if married (even if you
were not married in 2010) must provide the following information before any financial aid funds are
awarded. Enter zero (0) where appropriate; do not leave any item blank. You must sign this form on the
Forward the completed form, along with a signed copy of your (and your spouse’s) 2010 Federal Income
Tax Return to the Financial Aid Office at Bridgewater State University, Tillinghast Hall,
Bridgewater, MA 02325.
Student Name: __________________________________________________Social Security # XXX – XX -_________
Permanent Address: ______________________________________________________________________________
Permanent Phone: (____) ______________________ Email Address: ____________________________________
Marital Status: Single_____ Married_____ Divorced_____ Separated_____ Widowed_____
Fill in the information about the people in your household that you will support* between July 1, 2011 and June 30,
2012. Include yourself and your spouse. Include your children if they get more than half their support from you.
Include other people only if they meet the following criteria: they now live with you, and, they now get more than
half their support from you and they will continue to get this support between July 1, 2011 and June 30, 2012.
Full Name Age Relationship to College Attending in 2011-2012**
Self Bridgewater State University
*Support includes money, gifts, loans, housing, food, clothes, car, medical and dental care, payment of college costs, etc.
**Must be accepted in a degree program and attending college at least half-time in 2011/2012 (6 credits or more per semester).
COMPLETE BOTH SIDES AND SIGN ON REVERSE SIDE
Federal Tax Return Information
Tax Status Statement
Check applicable box Student/Spouse
I (we) have filed a tax return. Check and attach 2010 Federal Income Tax Return.
Include all W-2 forms and all schedules.
I (we) have requested a filing extension from the IRS for the 2010 tax year. Attach a
copy of Form 4868.
I (we) did not and will not file a 2010 Federal Income Tax Return because I (we) am
not required to do so. Attach all W-2 Forms
Income received from the following sources (Please check appropriate boxes below)
Welfare Benefits including Temporary Assistance to Needy Families (TANF)
Food Stamps or Subsidized Housing
Social Security Benefits received for all household members that were not taxed (such as SSI)
Untaxed Income Received in 2010
Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings),
$ including amounts reported on the W-2 Form in Box 12a – 12d, codes D, E, F, G, H, and S
IRA deductions and payments to self-employed SEP, SIMPLE, and Keogh and other qualified plans
$ from IRS Form 1040 – line 28 + 32 or 1040A – line 17
$ Child support received for all children. Do not include foster care or adoption payments.
$ Tax exempt interest income from IRS Form 1040 – line 8b 0r 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).
Veterans non-education benefits such as Disability, Death Pension, or Dependency & Indemnity
$ Compensation (DIC) and/or VA Educational Work-Study allowances
Any other untaxed income or benefits not reported, such as worker’s compensation, disability, etc.
Don’t include student aid, earned income credit, additional child tax credit, welfare payments,
untaxed Social Security benefits, Workforce Investment Act educational benefits, combat pay,
$ 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.
Student 2010 Additional Financial Information
$ Education credits (Hope and Lifetime Learning Tax credits) from IRS From 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, as reported on FAFSA.
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. Combat pay is reported on the W-2 in Box 12, Code Q.
$ Earnings from work under a cooperative education program offered by a college.
By my signature, I certify that all information submitted with and written on this application is complete, accurate,
and that corrections may be made based on data provided.
WARNING: If you purposely give false
or misleading information on this
___________________________________________________ worksheet, you may be fined, be
Student Signature Date sentenced to jail, or both.