FOOTHI LL COLLEGE DE ANZA COLLEGE
FINANCIAL AID OFFICE FINANCIAL AID OFFICE
12345 El Monte Rd 21250 Stevens Creek Blvd
Los Altos Hills CA 94022-4599 Cupertino, CA 95014-5793
2011-2012
DEPENDENT VERI FI CATI ON WORKSHEET
$SSOLFDQWVName _____________________________________________ SI D__________________________
Last First
Your federal financial aid application was selected by the Iederal processor Ior a process called 'VeriIication.
We must compare the information reported on the Free Application for Federal Student Aid (FAFSA) to signed
copies of 2010 federal income tax forms for both you and your parent(s). If there are differences between your
application and the documents, we will need to report the corrected information to the processor.
SECTI ON A. Family I nformation
List the people who your parent(s) will support between July 1, 2011 and June 30, 2012.
List yourself first (even if you do not live with them).
List your parent(s) (including stepparents)
List your parent(s) dependent children if they provide more than one-half of their support.
List your parent(s) children who attend college and are considered dependent for financial aid.
List other people who your parent(s) support by paying more than half of their expenses from
your parent(s) income and will continue to do so during the 11-12 school year. These people
must also be living with them. Do not include any people who live with them but support
themselves with their own income, even if they share some expenses.
Full Name
Age
Relationship
Name of College (list only if
attendance half-time or more during 11-12 year)
Student Applicant Self
If you need more space, attach a separate page.
Section B. Student Tax Forms and I ncome I nformation
_____I HAD THE FOLLOWI NG SOURCES OF UNTAXED I NCOME Total amount received in 2010
Social Security received (SSI, SSA, SSD, SDI) $___________________________
Welfare (TANF, General Assistance) received $___________________________
Did you receive free rent? Yes Value of free rent $_____________
Did you receive financial aid? Yes Where? _____________________
Other (please state)________________________________ $___________________________
_____I FI LED A 2010 FEDERAL I NCOME TAX FORM (IRS Form 1040, 1040A, or 1040EZ).
Please attach a SI GNED copy. Also include copies of W2(s) AND ALL ATTACHMENTS (PAGES) submitted to
the Internal Revenue Service. If you did not keep a copy of the tax return before mailing them to the IRS, you may
contact the IRS at 1-800-8908-9946 or complete form 4506-T to request a copy. This form is available on the IRS
website at [Link].
_____I DI D NOT FI LE, I AM NOT REQUI RED TO FI LE, AND WI LL NOT FI LE a 2010 federal income tax form.
Please list below all of the sources and amounts of money you received from January 2010 through December 2010.
Attach a copy of your W-2(s).
Employer(s) 2010 Amount
$
$
If you need more space, attach a separate page.
OVER
Applicant`s Name_______________________________________ SID ___________________________
Last First
Section C. Parent(s) Tax Forms and I ncome I nformation
_____MY PARENT(S) HAD THE FOLLOWI NG SOURCES OF UNTAXED I NCOME This could include cash
earned for odd jobs, child support, cash received from other family members or friends, money earned in another country,
unemployment assistance, back pay received from former employers, TANF, Social Security benefits, General Assistance,
money paid on your behalf, etc.
Total amount received in 2010
Child Support received $___________________________
Social Security received (SSI, SSA, SSD, SDI) $___________________________
Welfare (TANF, General Assistance) received $_____________________________
Did your parents receive free rent? Yes Value of free rent $______________
Other (please state)___________________________ $___________________________
_____MY PARENT(S) FI LED A 2010 FEDERAL I NCOME TAX FORM (IRS Form 1040,1040A, or 1040EZ).
Please attach a SI GNED COPY. If parents filed taxes separately, attach signed copies of both forms. Also include copies
of W2(s) AND ALL ATTACHMENTS (PAGES) submitted to the Internal Revenue Service. If they did not keep a
copy of the tax return before mailing them to the IRS, they can contact the IRS at 1-800-908-9946 or complete form
4506-T to request a copy. This form is available on the IRS website at [Link].
_____MY PARENT(S) DI D NOT FI LE, ARE NOT REQUI RED TO FI LE, AND WI LL NOT FI LE a 2010
federal income tax form. Please list below all of the sources and amounts of money your parents received from January 2010
through December 2010. Attach a copy of their W-2(s).
Employer(s) 2010 Amount
$
$
$
$
If you need more space, attach a separate page.
Low I ncomes:
If you are reporting yearly income below these amounts, please submit the Parent I ncome
Certification form (printed from our website) to help us understand your situation.
Household Size Income Under Household Size Income Under
1 $7,500 4 $13,500
2 $9,500 5 $15,500
3 $11,500 6 $17,500
Section D. Sign This Worksheet
By signing this worksheet, we certify that all the information reported to qualify for federal student aid is complete
and correct. I understand that periodically additional documents and/or information may be requested of me and my
family by the Financial Aid Office. At least one parent must sign the form.
______________________________________________ ______________________________________________
Student`s Signature Date Parent`s Signature Date
