2004-2005 Verification Worksheet
UTPA Student Financial Services 1201 W. University Drive, SSB 186 Edinburg, Texas 78540 (956) 381-2501
I
Independent Student
Federal Student Aid Programs
Your application was selected for review in a process called “Verification”. In this process, UTPA will be comparing information from your application with signed copies from your (and your spouse’s if you are married) 2003 Federal tax forms, W-2 forms and other financial documents. The law says we have the right to ask you for this information before awarding Federal Aid. If there are differences between your application information and the documents you submitted, UTPA may request corrections electronically. Please complete this verification form and submit it to the Student Financial Services office as soon as possible so that your financial aid will not be delayed.
What you should do
• • • • •
Collect yours (and your spouse’s if you are married) financial documents (signed 2003 Federal Income tax forms, W-2 forms, etc). Come by the Student Financial Services office if you need assistance completing this worksheet. You (and your spouse) must complete the worksheet. Take the completed worksheet, tax forms, and any other documents requested to the Student Financial Services office. A financial aid officer will compare information on all documents and you will be contacted if additional information is needed.
We are required under the financial aid program rules CFR Title 34, Part 668) to review this information.
PLEASE PRINT
A. Student Information
Last Name Mailing Address City State Zip Code First Name MI Social Security Number Date of Birth Phone Number
B. Family Information
List the people that you (and your spouse) will support more than 50% between July 1, 2004 and June 30, 2005. Always include: • Yourself (and your spouse) and • Your spouse’s other children if you and your spouse will provide more than half of their support between the dates mentioned above. Include other people as part of your family ONLY IF: 1. They live with you and your spouse and 2. You will provide more than half of their support AND 3. They will continue to get more than half of this support between July 1, 2004 and June 30, 2005. NOTE: A SEPARATE SUPPORT FORM NEEDS TO BE COMPLETED FOR OTHER PEOPLE (ex. grandparents, aunt/uncle, brother/sister over 24, etc.) REPORTED IN THE AREA BELOW. Write in the names of all family members, including you. Also write in the name of the college for any family member who will be attending college at least half -time between July 1, 2004 and June 30, 2005, enrolled in a degree program at least half-time. If you need more space, attach a separate page. FULL NAME (print) AGE RELATIONSHIP COLLEGE ATTENDING DURING 2004-2005
C. Student’s Tax Forms and Income Information (all applicants)
Independent
1. Check one box only. Tax returns include the 2003 IRS Form 1040, 1040A, 1040EZ, Tele-file Tax Record, a tax return from Puerto Rico or a foreign tax return. If you did not keep a copy of the tax return, request a copy from your tax preparer or request a copy of Internal Revenue Service (IRS) form that lists tax account information. IRS Phone #: (1-800-829-1040) Check and attach signed tax return. Check here if you will not file and are not required to file a 2003 U.S. Income Tax Return.
2. Funds received for child support, social security and other untaxed income in 2003.
Child Support (received) Social Security Other $ $ $
3.
If you did not file a 2003 Federal Income Tax Return, list your employer(s) and any income received in 2003.
Sources (use W-2 form or other earnings statement)
$ $
4.
Amounts reported as exclusions on Worksheet C on the FAFSA for 2003.
Child Support (paid) Work Study Earnings Other $ $ $
D. Spouse’s Tax Forms and Income Information (If Student Is Married)
Check and attach signed tax return. Check here if you will not file and are not required to file a 2003 U.S. Income Tax Return.
2. Funds received for child support, social security and other untaxed income in 2003.
Child Support Social Security Other $ $ $
3. If you did not file a 2003 Federal Income Tax Return, list your employer(s) and any income received in 2003.
Sources (use W-2 form or other earnings statement)
$ $
4. Amounts reported as exclusions on Worksheet C on the FAFSA for 2003.
Child Support (paid) $ Work Study Earnings Other $ $
E. SIGN THIS WORKSHEET
Don’t’ forget to sign your tax forms!
Warning: If you purposely give false or mi information on this worksheet, you may be f sentenced to jail or both.
By signing this worksheet, I (we) certify that all the information reported on this Worksheet is complete and correct.
__________________________________________ Student’s Signature
______________ Date Student’s Social Security Number
Spouse’s Signature (optional)
Date
Student’s Email Address
Do not mail this worksheet to the Department of Education. Mail or take it to UTPA Student Financial Services SSB, 186, 1201 W. University Dr., Edinburg, Texas 78541.
NOTE: Disclosure of your Social Security Number (SSN) is required of you in order for The University of Texas- Pan American’s Student Financial Services Office to process required documents as mandated by Federal/State law. Further disclosure of your SSN is governed by the Public Information Act (Chpt. 552 of the Texas Government Code) and other applicable law. As per HB 1922 (Subtitle A, Title 5, Government Code, Chapter 559), it is the policy of the state that an individual is entitled, on request, to receive, review and/or correct any information about the individual, which has been submitted to UTPA, with few exceptions. The information that UTPA collects will be retained and maintained as required by Texas records retention laws (Section 441.180 et seq. of the Texas Government Code) and rules.