Independent Verification Worksheet
You were selected for a review process called “Verification”. Information on this form will be compared to your FAFSA to
verify the income was reported accurately. Please complete the entire worksheet. Incomplete worksheets will not be
Student’s Name: ID #
HOUSEHOLD SIZE VERIFICATION – Follow these instructions to identify who you should include in
your household size:
1. List the people in your household you and your spouse will support between July 1, 2012, and June 30, 2013, in the
box below. Include:
Yourself and your spouse (if married and not separated when you filed the FAFSA)
Your children, if you will provide more than half of their support from July 1, 2012, through June 30, 2013,
OR if they would be required to provide information when applying for Federal Student Aid, and
Other people ONLY if they now live with you and you provide more than half of their support AND will
continue to provide more than half of their support from July 1, 2012, through June 30, 2013.
2. Write in the name of the college for any household member, excluding your parent(s), who will be attending
college, at least half-time between July 1, 2012, and June 30, 2013, and will be enrolled in a degree, diploma or
certificate program. If you need more space, attach a separate sheet.
Full Name Age Relationship to Student Name of College
Peralta Community College District
Berkeley City College College of Alameda Laney College Merritt College
2050 Center Street 555 Atlantic Avenue 900 Fallon Street 12500 Campus Drive
Berkeley, CA 94704 Alameda, CA 94501 Oakland, CA 94607 Oakland, CA 94619
FAFSA School Code: 014311 FAFSA School Code: 006720 FAFSA School Code: 001266 FAFSA School Code: 001267
Student’s Name: ID #
INDEPENDENT STUDENT’S 2011 INCOME INFORMATION
1. TAX RETURN FILERS – Complete this section ONLY if the student and spouse (if married) filed or will
a 2011 income tax return with the Internal Revenue Service (IRS).
Instructions: The best way to verify income is by using the IRS Data Retrieval Tool available on FAFSA on the
Web (FOTW). If the student has not already used the tool, go to www.FAFSA.gov, log in to the student’s FAFSA,
select “Make FAFSA Corrections,” and navigate to the Financial Information section of the form. From there, follow
the instructions to determine if the student is eligible to use the IRS Data Retrieval Tool to transfer 2011 IRS
income tax information into the student’s FAFSA. Here are some reasons why the IRS Data Retrieval Tool may not
Married independent applicant and spouse filed separate tax returns.
Parents of dependent student file separate tax returns.
When an applicant or parent had a change in marital status after 12-31-11.
When an applicant, parent or spouse filed an amended tax return.
Check the box that applies:
I, the student (and spouse if married) have used the IRS Data Retrieval Tool in FOTW to retrieve and
transfer 2011 IRS income information into my FAFSA.
I, the student (and spouse if married) am unable to use the IRS Data Retrieval Tool in FOTW and have
attached a copy of a 2011 IRS Tax Return Transcript – not a photocopy of the income tax return. There
are three (3) ways to obtain an IRS Tax Return Transcript:
1. Online – Go to www.irs.gov and click on Order a Return or Account Transcript
2. Call 1-800-908-9946 and follow the voice prompts, or
3. Mail – IRS Form 4506-T, Request for Transcript of Tax Return. IRS forms are available online at
www.irs.gov or by calling 1-800-829-3676.
You will need to gather the following information to order your IRS Tax Return Transcript:
Social Security Number (or your IRS individual taxpayer identification number);
Date of birth;
Street address; and
Zip Code or Postal Code.
2. TAX RETURN NON-FILERS – Complete this section if the student and spouse (if married) will not file
and is not required to file a 2011 income tax return with the IRS.
Check the box that applies:
I, the student (and spouse if married) was not employed and had no income earned from work in 2011.
I, the student (and spouse if married) was employed in 2011 and did not file taxes. List the names of all
the employers, the amount earned from each employer in 2011, and whether an IRS W-2 is attached.
Attach copies of all 2011 IRS W-2 forms issued by employers. List every employer even if
they did not issue an IRS W-2 form. If more space is needed, attach a separate page with the student’s
name and school ID number at the top of the page.
2011 Amount IRS W-2
Employers Name Student Spouse Earned Attached?
X $2,000 Yes
Lakeshore Drive In (example) (example) (example) (example)
Student’s Name: ID #
INDEPENDENT STUDENT’S INFORMATION
Check this box if someone in your household (listed in the Household Size Verification section) received benefits
from the Supplemental Nutrition Assistance Program or SNAP (formerly known as Food Stamps) any time during 2010 or
2011. If asked by the college, I will provide documentation of the receipt of SNAP benefits during 2010 and/or 2011.
Check this box and complete this section if you or your spouse (if married), listed in the Household Size
Verification section, paid child support during 2011.
Name of Person who Paid Name of Person to Whom Name of Child for Whom Amount of Child Support
Child Support Child Support was Paid Support was Paid Paid in 2011
Marty Jones (example) Chris Smith (example) Terry Jones (example) $6,000 (example)
UNTAXED INCOME – Enter all untaxed income received in 2011 or $0.00 if none.
Untaxed Income Student Spouse
Child Support RECEIVED – DO NOT include foster care payments: $ $
Payments to tax-deferred pension and savings plan (paid directly or withheld from
earnings) including, but not limited to, amounts reported on the W-2 in box 12a through $ $
12d codes D, E, F, G, H and S:
Housing, food, or other allowances paid to members of the military, clergy, and others
(including cash payments and cash value of benefits)
Veteran’s non-education benefits such as Disability, Death Pension, or Dependency &
Indemnity Compensation (DIC) and/or VA Educational Work Study allowances
Non-Federal Disability Benefits, Untaxed Pensions or Workers Compensation (Do not
include any type of Social Security Benefits):
Unemployment benefits that were not reported on your tax return: $ $
Any money given to you by someone else (for bills, rent, utilities, etc.): $ $
By signing below, I certify the information reported on this worksheet is complete and accurate and authorize
the Financial Aid Office to perform necessary electronic ISIR corrections on my behalf. If asked by the college, I
agree to provide proof of any information reported on this form or on my FAFSA. I realize that any false
statement or failure to give proof when asked may be cause for the denial, reduction, withdrawal, and/or
repayment of my financial aid. I also understand if I purposely give false or misleading information I may be
fined up to $20,000, sentenced to jail, or both.
Student Signature: Date: