2014–2015 Household Resources Verification
Worksheet
Dependent Student
Your 2014–2015 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification. The law says
that before awarding Federal Student Aid, we may ask you to confirm the information you and your parent(s) reported on your FAFSA.
To verify that you provided correct information, the Clarion Student Financial Services (SFS) Office staff will compare your FAFSA with
the information on this worksheet and with any other required documents. If there are differences, your FAFSA information may need to
be corrected. You and at least one parent must complete and sign this worksheet, attach any required documents, and submit the form and
other required documents to the SFS Office. Clarion may ask for additional information.
A. Dependent Student’s Information
______________________________________________________________
Student’s Last Name
Student’s First Name
Student’s M.I.

___________________________________
Student’s Clarion ID Number

______________________________________________________________
Student’s Street Address (include apt. no.)

___________________________________
Student’s Date of Birth

______________________________________________________________
City
State
Zip Code

___________________________________
Student’s Alternate or Cell Phone Number

______________________________________________________________
Student’s Home Phone Number (include area code)
B. Dependent Student’s Family Information
List below the people in your parent(s)’ household. Include:
 The student.
 The parents (including a stepparent) even if the student doesn’t live with the parents.
 Your parent(s)’ other children if your parent(s) will provide more than half of the children’s support from July 1, 2014,
through June 30, 2015, or if the other children would be required to provide parental information if they were completing a
FAFSA for 2014–2015. Include children who meet either of these standards even if the children do not live with the
parent(s).
 Other people if they now live with your parent(s) and your parent(s) provide more than half of their support and will
continue to provide more than half of their support through June 30, 2015.
Include the name of the college for any household member, excluding your parent(s), who will be enrolled at least half time
in a degree, diploma, or certificate program at an eligible postsecondary educational institution any time between July 1, 2014,
and June 30, 2015. Please contact the SFS Office if your parent(s) will be enrolled in a degree program at least half-time
during the 2014-15 academic year.
Full Name

Age

Relationship
Self

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College
Clarion University

Will be Enrolled at
Least Half Time

C. Dependent Student’s Income Information to Be Verified

1.

TAX RETURN FILERS—Important Note: If the student filed, or will file, an amended 2013 IRS tax return, the student must
contact the Student Financial Services Office before completing this section.
Instructions: Complete this section if the student, filed or will file a 2013 IRS income tax return. The best way to verify income
is by using the IRS Data Retrieval Tool (IRS DRT) that is part of the electronic FAFSA application (www.fafsa.ed.gov).
Typically, no further documentation is needed to verify 2013 income information that was transferred into the student’s
FAFSA using the IRS DRT if that information was not changed.
In most cases, for electronic tax return filers, 2013 IRS income tax return information for the IRS DRT is available within 2-3
weeks after the 2013 electronic IRS income tax return has been accepted by the IRS. Generally, for filers of 2013 paper IRS
income tax returns, the 2013 IRS income tax return information is available for the IRS DRT within 6-10 weeks after the 2013
paper IRS income tax return has been received by the IRS. Contact the SFS Office if more information is needed about using
the IRS DRT.
Check the box that applies:
The student has used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2013 IRS income tax return
information into the student’s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA.
The student has not yet used the IRS Data Retrieval Tool in FAFSA on the Web, but will use the tool to transfer 2013 IRS
income tax return information into the student’s FAFSA once the 2013 IRS income tax return has been filed.
The student is unable, or chooses not to use the IRS Data Retrieval Tool in FAFSA on the Web, and instead will provide
the school a 2013 IRS Tax Return Transcript.
To obtain a 2013 IRS Tax Return Transcript, go to www.IRS.gov and click on the “Get Transcript of your Tax
Records” link under the heading “Tools”. You will then have the choice between receiving your transcript online or by
mail. We recommend choosing “Get Transcript Online” because you will be able to instantly view and print a copy of
your 2013 Tax Return Transcript. When ordering your transcript online, you will be asked to sign in with your user ID. If
you have not created an account before, please create a new account now. Once you have created an account and you have
signed in, you will be able to select a 2013 Tax Return Transcript.
If you choose “Get Transcript by Mail”, please enter all required information and then select “2013 Tax Return
Transcript”. Your transcript will generally be sent to you via US mail within 5-10 calendar days.
Check here if the student’s IRS Tax Return Transcript is attached to this worksheet.
Check here if the student’s IRS Tax Return Transcript will be submitted to Clarion later. Verification cannot be
completed until the IRS tax return transcript has been submitted to the SFS Office.

2.

TAX RETURN NONFILERS—complete this section if the student, WILL NOT file AND is not required to file a 2013 income
tax return with the IRS.
Check the box that applies:
I was not employed and had no income earned from work in 2013.
I was employed in 2013 and have listed below the names of all the student’s employers and the amount earned from each
employer in 2013.
Employer’s Name
Suzy’s Auto Body Shop (example)

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2013 Amount Earned
$2,000.00(example)

Student’s Name: __________________________________________ Clarion ID: __________________________
D. Parent’s Income Information to be verified—Note: If two parents were reported in Section B of this worksheet, the
instructions and certifications below refer and apply to both parents.
1. TAX RETURN FILERS—Important Note: If your parent(s), filed or will file, an amended 2013 IRS tax return or filed
separate 2013 tax forms, you must contact the SFS Office before completing this section.
Instructions: Complete this section if your parent(s) filed or will file a 2013 IRS income tax return(s). The best way to verify
income is by using the IRS Data Retrieval Tool (IRS DRT) that is part of the electronic FAFSA application (www.fafsa.ed.gov).
Typically, no further documentation is needed to verify 2013 income information that was transferred into the student’s
FAFSA using the IRS DRT if that information was not changed.
In most cases, for electronic tax return filers, 2013 IRS income tax return information for the IRS DRT is available within 2-3
weeks after the 2013 electronic IRS income tax return has been accepted by the IRS. Generally, for filers of 2013 paper IRS
income tax returns, the 2013 IRS income tax return information is available for the IRS DRT within 6-10 weeks after the 2013
paper IRS income tax return has been received by the IRS. Contact the SFS Office if more information is needed about using
the IRS DRT.
Check the box that applies:
Parent(s) have used the IRS Data Retrieval Tool in FAFSA on the Web to transfer 2013 IRS income tax return information
into the student’s FAFSA, either on the initial FAFSA or when making a correction to the FAFSA.
Parent(s) have not yet used the IRS Data Retrieval Tool in FAFSA on the Web, but will use the tool to transfer 2013 IRS
income tax return information into the student’s FAFSA once the 2013 IRS income tax return has been filed.
Parent(s) are unable, or choose not to use the IRS Data Retrieval Tool in FAFSA on the Web, and instead will provide the
school a 2013 IRS Tax Return Transcript.
To obtain a 2013 IRS Tax Return Transcript, your parent(s) should go to www.IRS.gov and click on the “Get Transcript
of your Tax Records” link under the heading “Tools”. They will then have the choice between receiving their transcript
online or by mail. We recommend choosing “Get Transcript Online” because they will be able to instantly view and print
a copy of their 2013 Tax Return Transcript. When ordering their transcript online, they will be asked to sign in with their
user ID. If they have not created an account before, they should do so now. Once they have created an account and have
signed in, they will be able to select “2013 Tax Return Transcript”.
If your parent(s) choose “Get Transcript by Mail”, please enter all required information and then select “2013 Tax Return
Transcript”. Their transcript will generally be sent to them via US mail within 5-10 calendar days.
If your parent(s) filed separate 2013 IRS income tax returns, 2013 Tax Return Transcripts must be provided for both.
Check here if the parent(s)’ IRS Tax Return Transcript(s) is attached to this worksheet.
Check here if the parent(s)’ IRS Tax Return Transcript(s) will be submitted to Clarion later. Verification cannot be
completed until the IRS tax return transcript has been submitted to the SFS Office.
2. TAX RETURN NONFILERS—complete this section if your parent(s), WILL NOT file AND are not required to file a 2013
income tax return with the IRS.
Check the box that applies:
My parent(s) was/were not employed and had no income earned from work in 2013.
My parent(s) was/were employed in 2013 and has listed below the names of all the parent’s employers and the amount
earned from each employer in 2013. Attach SIGNED copies of all 2013 IRS W-2 forms issued to the parent(s) by
employer(s). List every employer, even if they did not issue an IRS W-2 form.
Employer’s Name

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2013 Amount Earned

E. Parent’s Other Information to Be Verified
1. Complete this section if someone in your parent’s household (listed in Section B) received benefits from the Supplemental
Nutrition Assistance Program or SNAP (formerly known as food stamps) any time during the 2012 or 2013 calendar years.
SNAP may be known by another name in some states. For assistance in determining the name used in a state, please call 1800-4FED-AID (1-800-433-3243).
The parent(s) certify that __________________________, received SNAP benefits in 2012 or 2013. If asked by Clarion’s
SFS Office, I will provide documentation of the receipt of SNAP benefits during 2012 and/or 2013.

2. Complete this section if one of your parents in the household paid child support in 2013.
One (or both) of your parents listed in Section B of this worksheet paid child support in 2013. List below the name(s) of
the person who paid the child support, the name(s) of the person to whom the child support was paid, the names of the
children for whom child support was paid, and the total annual amount of child support that was paid in 2013 for each
child. If asked by Clarion, I will provide documentation of the payment of child support. If you need more space, attach a
separate page that includes the student’s name and Clarion ID number at the top.

Name of Person Who Paid
Child Support

Name of Person to Whom Child
Support was Paid

Name of Child for Whom
Support Was Paid

Marty Jones

Chris Smith (example)

Terry Jones

Amount of Child
Support Paid in
2013
$6,000.00

F. Verification of Other Untaxed Income for 2013
If any item does not apply, enter “N/A” for Not applicable where a response is requested, or enter $0 in an area where an
amount is requested.
If the student was required to provide parental information on the FAFSA, answer each question below as it applies to the
student and the student’s parent(s) whose information is on the FAFSA.
To determine the correct annual amount for each item: If you paid or received the same dollar amount every month in
2013, multiply that amount by the number of months in 2013 you paid or received it. If you did not pay or receive the same
amount each month in 2013, add together the amounts you paid or received each month.
1.

Payments to tax-deferred pension and retirement savings
List any payments (direct or withheld from earnings) to tax-deferred pension and retirement savings plan (e.g., 4-1(k) or
403(b) plans), including, but not limited to, amounts reported on W-2 forms in Boxes 12a through 12d with codes D, E, F,
G, H, and S.
Name of Person Who Made the Payment

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Total Amount Paid in 2013

Student’s Name: __________________________________________ Clarion ID: __________________________
2.

Child support received
List the actual amount of any child support received in 2013 for the children in your household.
Do not include foster care payments, adoption payments, or any amount that was court-ordered, but not actually paid.

Name of Adult Who Received the
Support

3.

Name of Child For Whom Support Was
Received

Amount of Child Support Received in
2013

Housing, food, and other living allowances paid to members of the military, clergy, and others
Include cash payments and/or the cash value of benefits received.
Do not include the value of on-base military housing or the value of a basic military allowance.
Name of Recipient

4.

Type of Benefit Received

Amount of Benefit Received in 2013

Veterans non-educational benefits
List the total amount of veterans non-education benefits received in 2013. Include Disability, Death Pension,
Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances.
Do not include federal veterans’ educational benefits such as: Montgomery GI Bill, Dependents Education Assistance
Program, VEAP Benefits, or Post-9/11 GI Bill.
Name of Recipient

5.

Type of Veterans Non-educational Benefit

Amount of Benefit Received in 2013

Other untaxed income
List the amount of other untaxed income not reported and not excluded elsewhere on this form. Include untaxed income
such as workers’ compensation, disability, Black Lung Benefits, untaxed portions of health savings accounts from IRS
Form 1040 Line 25, Railroad Retirement Benefits, etc.
Do not include any items reported or excluded in 1-4 above. In addition, do not include student aid, Earned Income
Credit, Additional Child Tax Credit, Temporary Assistance to Needy Families (TANF), untaxed Social Security benefits,
Supplemental Security Income (SSI), Workforce Investment Act (WIA) educational benefits, Supplemental Security
Income (SSI), spending arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special
fuels.
Name of Recipient

6.

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Type of Other Untaxed Income

Amount of Other Untaxed Income
Received in 2013

Money received or paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g., payment of student’s bills) and not reported elsewhere
on this form. Enter the total amount of cash support the student received in 2013. Include support from a parent whose
information was not reported on the student’s 2014-2015 FAFSA, but do not include support from a parent whose
information was reported. For example, if someone is paying rent, utility bills, etc., for the student or gives cash, gift

cards, etc., include the amount of that person’s contributions unless the person is the student’s parent whose
information is reported on the student’s 2014-2015 FAFSA. Amounts paid on the student’s behalf also include any
distributions to the student from a 529 plan owned by someone other than the student or the student’s parents, such as
grandparents, aunts, and uncles of the student.
Purpose: e.g., Cash, Rent, Books

7.

Amount Received in 2013

Source

Additional Information
So that we can fully understand the student’s family’s financial situation, please provide below information about any
other resources, benefits, and other amounts received by the student or any members of the student’s household. This may
include items that were not required to be reported on the FAFSA or other forms submitted to the financial aid office, and
include such things as federal benefits education benefits, military housing, SNAP, TANF, etc.
If more space is needed, provide a separate page with the student’s name and ID number at the top.
Name of Recipient

Type of Financial Support

Amount of Financial Support Received
in 2013

Please include any additional comments you would like to make about any of the provided information on a separate sheet of paper
that includes the student’s name and ID number.

G.

Certification and Signatures
Each person signing below certifies that all of the
Information reported is complete and correct. The student
And one parent whose information was reported on the
FAFSA must sign and date.

WARNING: If you purposely give false or misleading
information on this worksheet, you may be fined, be
sentenced to jail, or both.

_________________________________________________
Student’s Signature

_________________________________
Date

_________________________________________________
Parent’s Signature

_________________________________
Date

Do not mail this worksheet to the U.S. Department of Education.
Submit this worksheet to:
Student Financial Services Office
B-16 Carrier Hall
Clarion University of Pennsylvania
Clarion, PA 16214
(You should make a copy of this worksheet for your records.)

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