Ucla Dependent Verification Form – Fill Out and Use This PDF

Your file has been selected for verification of the data provided on your Free Application for Federal Student Aid (FAFSA). We cannot evaluate your eligibility for financial aid until you submit all required verification documents. Delays in completion and submittal of this form may result in limited funding for 2012-13.

Please check this box if you will be enrolled in the Summer 2012.

STUDENT TAX FORM AND INCOME INFORMATION (Check One)

 I have attached a complete and signed copy of my 2011 tax return (IRS Form 1040/1040A/ 1040EZ), including all schedules, statements and W2 forms or IRS tax filing extension form 4868 and verification of income (see instructions on verification checklist).

I will not file a 2011 tax return (IRS Form 1040/1040A/1040EZ). List any income received in 2011. Please attach verification of income received (i.e. W2’s, 1099-misc, SSI statements, etc).

DO NOT leave blank. If no income, report “0” $__________________

PARENT TAX FORM AND INCOME INFORMATION (Check One)

 I/we have attached a complete and signed copy of my/our 2011 tax return (IRS Form 1040/1040A/1040EZ), including all schedules, statements and W2 forms or IRS tax filing extension form 4868 and verification of income (see instructions on verification checklist).

I will not file a 2011 tax return (IRS Form 1040/1040A/1040EZ). List any income received in 2011 on the Parents’ Statement of Expenses and Recourses on page 2.

HOUSEHOLD INFORMATION

Please list your parent(s) and their dependents for the 2012-2013 academic year below. Include yourself, your parent(s), and your parent(s) other dependent children. Only include other people that live with and will receive at least half of their support from your parent(s) during the entire period from 7/1/12 to 6/30/13.

*College must be eligible to participate in Title IV programs.

UID# _______________________________

PARENTS’ STATEMENT OF EXPENSES AND RESOURCES

Please itemize both your monthly and yearly expenses and list all sources of income from January 1, 2011 to December 31, 2011. Do not include expenses that relate to family businesses, rental property, or college costs for you or your children.

2 of 4

UID# _______________________________

Please report asset values for all that applies. Report all values as of the date the FAFSA was completed. Only list the percentage you own of the value and debt of assets below. Please read the Dependent Verification Checklist for more instructions on what to include as an “Investment” or “Real Estate” asset. Attach additional pages if necessary.

3 of 4

UID# _______________________________

OTHER INFORMATION TO BE VERFIFIED

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM or SNAP

If you or a member in the student’s parent’s household received benefits from Supplemental Nutrition Assistance Program SNAP (formerly known as food stamps) anytime during 2010 and/or 2011.

Yes, SNAP benefits were received in 2010 and/or 2011.

No, SNAP benefits were not received in 2010 and/or 2011.

No documentation needed.

CHILD SUPPORT PAID

Complete these section if one of the student’s parent (s) paid child support in 2011. No, parent’s did not pay child support in 2011.

One (or both) of the student’s parent (s) listed in household information of this worksheet paid child support in 2011. The parent has indicated below the name of the person who paid child support, the name of the person to whom the child support was paid, names of the children for whom child support was paid, and the total amount of child support that was paid in 2011 for each child. If you need more space, attach a separate page that includes the student’s name and student ID# at the top of the page.

Please attach proof of the child support payments made in 2011.

CERTIFICATION STATEMENT

I certify that all the information reported on this form is complete and accurate. I understand that I may be required to provide additional documentation. Purposely providing false or misleading information on this worksheet may result in an investigation by the Inspector General for Student Aid Fraud. I understand that certain awards (ex: University Grants) are subject to availability of funds that may not be available if the form is submitted late in the academic year.

Is the 2012-2013 Verification form completely filled out and signed by the student and the parent? Do not leave BLANKS. Please answer with a “0” or “N/A” if there is no value to report.

Have you attached a signed copy of your and your parent (s) 2011 Federal Tax returns (IRS Form 1040/1040A/1040EZ) and all supporting statements and schedules? DO NOT SUBMIT STATE TAX

RETURNS AND SCHEDULES.

Have you attached copies of all student and parent (s) 2011 W-2’s?

Have you masked (or whiteout) the first 5 digits of all social security numbers on all tax documents?

PLEASE NOTE:

1.Documentation submitted without the first five digits of Social Security Numbers masked will take longer to prepare for processing and delay the awarding of your file.

2.Incomplete verification forms and/or copies of taxes and schedules will delay the processing of your financial aid.

3.For Parent and Student Asset verification:

A. Investments include trust funds, money market funds, mutual funds, certificates of deposit (CD), stocks, stock-options, bonds, other securities, Coverdell savings accounts, 529 college savings plans, commodities, Uniform Transfers to Minors Act (UTMA)/Uniform Gifts to Minors Act (UGMA)

Custodial Accounts, Partnerships/S corporations—only report asset value If you own less than 50% of business. Do not include the value of life insurance and retirement plans (401[k] plans, pension funds, annuities, non-Education IRAs, Keogh plans).

B. Real estate includes rental property, land and second or summer homes. The value is the current market value. Debt equals how much your parents owe on the property. Include the value of multifamily dwellings that you own (exclude the portion of a dwelling that is your principal residence). Do not

include your primary residence (your home).

4.The federal deadline to submit verification documents is no later than 60 days after your last day of attendance or August 30th 2013, whichever is sooner. However, we encourage students to submit verification documents as soon as possible. Delays in completion and submittal of verification documents may result

in limited funding for 2012-13.

5.If you are unable to provide a federal tax return due to filing a tax extension, the Financial Aid Office may use discretion to provide an initial financial aid disbursement of federal aid based on a projection of your or your parents’ 2011 income. Please refer to the 2012-13 Verification Instructions for Tax Extension Filers’

guide at www.fao.ucla.edu.

6.You can check the status of your financial aid by logging into your “MyFAO” account at www.fao.ucla.edu.

Do not return this checklist to our office. It is for your reference only.