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|The Department of Education has selected your FAFSA for a review process called verification. In this process, the Office of Financial Aid will be comparing information|

|from your FAFSA with this worksheet and your IRS Data. Federal regulations require colleges to ask for this information before disbursing federal aid. If there are |

|differences between your application and the documents you provide, your FAFSA information will need to be corrected by your Financial Aid Administrator. Please read |

|all instructions carefully before completing this form to avoid delaying your financial aid awards. |

INSTRUCTIONS:

1. Make sure to check your Missing Information Letter on the InSite Portal.

2. Complete all required sections of this worksheet and sign below. In order to complete your financial aid file, you may be required to provide additional documentation.

3. If you, your spouse and/or your parent(s) received food stamps in 2011 or 2012, you may be required to submit documentation showing receipt of the SNAP benefit from the California Department of Social Services (CDSS) such as a Notice of Action.

SECTION A: STUDENT INFORMATION

___________________________________________________ __________________________________________

Last Name First Name Social Security Number/Student ID Number

___________________________________________________ __________________________________________

Address (include apt. no.) Date of Birth

___________________________________________________ (______)___________________________________

City State Zip Phone Number (include area code)

DEPENDENT STUDENT INDEPENDENT STUDENT

SECTION B: FOOD STAMP VERIFICATION

Check the box below if you (student), your spouse (if married) and/or your parent(s) (If dependent on the FAFSA) received benefits from the Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, any time during the 2011 or 2012 calendar years.

SECTION C: SIGN THIS WORKSHEET

By signing this form, I/we certify that all the information reported on is complete and correct. WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.

__________________________________________ _______________________________________________

Student Signature Date Parent Signature (for Dependent Students only) Date

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2013- 2014 V2 SNAP Verification Form

Los Medanos College

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