2015–2016 Child Support Paid Worksheet
Dependent Student

Your 2015–2016 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 parents 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.

Parents’ Other Information to Be Verified

One of the parents included in the household, or the student, paid child support in 2014. List below the names of the persons who
paid the child support, the names of the persons to whom the child support was paid, the names of the children for whom the child
support was paid, and the total annual amount of child support that was paid in 2014 for each child.
If more space is needed, provide a separate page that includes the student’s name and ID number at the top.

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Name of Person Who Paid
Child Support

Name of Person to Whom Child
Support was Paid

Name and Age of Child for
Whom Support Was Paid

Marty Jones(example)

Chris Smith

Terry Jones (Age 15)

Amount of Child
Support Paid in
2014
$6,000.00

Note: If we have reason to believe that the information regarding child support paid is not accurate, we may require additional
documentation, such as:


A copy of the separation agreement or divorce decree that shows the amount of child support to be provided;



A signed statement from the individual receiving the child support certifying the amount of child support received; or



Copies of the child support payment checks, money order receipts, or similar records of electronic payments having been
made.

C. Certification and Signatures
Each person signing this worksheet certifies that all of the
information reported on it is complete and correct.
The student and one parent 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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