Date due: June 1, 2000 .md.us



DEPENDENT STUDENT

2017-2018 Verification Worksheet

Guaranteed Access Grant

Return this form and all required documents to the Maryland Higher Education Commission by April 1, 2017.

If you have questions about this process, please contact us at (410) 767-3300 or (800) 974-0203.

Please check the following:

❑ All information on this Verification Worksheet has been completed.

❑ ONLY IF TAXES WERE FILED, my and / or my spouse’s 2015 IRS Tax Return Transcripts are attached (transcripts must be requested from the IRS: . If the IRS Data Retrieval Tool was used when filing the FAFSA the Tax Return Transcripts is not required for submission to the Maryland Higher Education Commission).

❑ Photocopies of student and / or the student spouse’s 2015 W-2 forms are attached (If the IRS Data Retrieval Tool was used when filing the FAFSA, W-2 form(s) are not required for submission to the Maryland Higher Education Commission).

Mail this completed worksheet and all required documents to: Maryland Higher Education Commission

Office of Student Financial Assistance

Attention: GA Grant Verification

6 N. Liberty Street, Ground Suite

Baltimore, MD 21201

If the financial information on your FAFSA is different from the information on your financial documents, your award may change.

• Your award amount may change or be canceled based upon the information you provide.

• Failure to comply with this verification process will result in the cancellation of your award.

• Forms received without documentation will not be reviewed and your award will be canceled.

SECTION A: Student Information (please print)

Last name: _______________________________________ First name: _____________________________ MI: ___________

Social Security Number: ____________ - ____________ - ____________ Date of birth: _________ /___________ /___________

Home telephone number: (________) ________ - ________ E-mail: _________________________________________________

Street Address: _______________________________________________________________________________________________

City: _________________________________________________________ State: ________________ Zip code: ________________

Complete name of the institution you will attend during the 2017-2018 academic year:_________________________________________

During the 2017-2018 school year, will you be living (check one) ο on-campus ο off-campus ο with parents or other family members

SECTION B: Family Information (please print)

List the people in your parents’ household, including:

• Yourself and your biological and/or adoptive parent(s) if both parents are living together (even if they are unmarried)

• Your step-parent (if your parent is married)

• Your parents, if you are a dependent student, even if you don’t live with your parent(s).

• Your parents’ other children [even if they don’t live with your parent(s)], if:

• your parents provide more than half of their support from July 1, 2017 through June 30, 2018, or

• the children would be required to provide parental information when applying for federal student aid.

• Other people living with your parents if your parents will provide more than half of their support from July 1, 2017 through June 30, 2018.

|FULL NAME |AGE |RELATIONSHIP |COLLEGE ATTENDING IN |

| | | |2016-2017 |

|Susan Smith (example) |18 |Sister |Central University |

| | |SELF | |

| | | | |

| | | | |

| | | | |

| | | | |

SECTION C: Tax Forms and Income Information

Check one box only. Federal tax transcripts are provided by the U.S. Internal Revenue Service by online request at under ONLINE SERVICES, by telephone request at 1-800-908-9946, or by written request using IRS Form 4506T-EZ.

Please note: THE MARYLAND HIGHER EDUCATION COMMISSION ENCOURAGES STUDENTS AND FAMILIES TO USE THE IRS DATA RETRIEVAL TOOL WHEN FILING THE FAFSA. IF THE IRS DATA RETRIEVAL TOOL IS USED, THE TAX RETURN TRANSCRIPT AND W-2 FORM(S) ARE NOT REQUIRED BY MARYLAND HIGHER EDUCATION COMMISSION FOR THE VERIFICATION PROCESS.

1. Student’s tax information, check one box ONLY:

❑ I have completed my 2015 Federal Income Tax form. (Attach Federal IRS Tax Return Transcript and W-2 form(s) and/or earnings statements.)

❑ I am not going to file/ have not filed my 2015 Federal Income Tax form because I am not required to file. (Attach any W-2 forms and/or earnings statement from employment held during 2015.)

2. Parent’s tax information, check one box ONLY:

❑ I have completed my 2015 Federal Income Tax form. (Attach Federal IRS Tax Return Transcript and W-2 forms and/or earnings statements.)

❑ I am not going to file/ have not filed my 2015 Federal Income Tax form because I am not required to file. (Attach any W-2 form(s) and/or earning statement from employment held during 2015.)

3. If you did not file and are not required to file a 2015 Federal Income Tax return, list below your employer(s) and any income received in 2015. (Use the W-2 form(s) or other earnings statement if available)

|Employer |2015 Income Amount for Student |2015 Income Amount for Parent(s) |

| | | |

| | | |

| | | |

4. Funds received for child support and other untaxed income. (See questions 44 and 92 on the FAFSA)

Please DO NOT leave boxes blank; use zeroes if you did not receive the type of income listed. Incomplete boxes are not accepted.

|Source of Untaxed Income |2015 Amount received by Student |2015 Amount received by Parent(s) |

|Child Support |$ |$ |

|Cash Support received |$ |$ |

|Payments to pension & savings plans |$ |$ |

|Other: |$ |$ |

|Other: |$ |$ |

Acceptable documentation for Child Support includes a photocopy of a court order or divorce decree, separation agreement, etc.

Section D: Sign this Worksheet

By signing this worksheet, we certify that all the information reported on it is complete and correct. (At least one parent must sign)

_________________________________________________ _____________________________________________

Student Date

_________________________________________________ _____________________________________________

Parent Date

WARNING: If you purposely give false or misleading information on this worksheet, you and your parents may be fined, be

sentenced to jail or both.

Under provisions of the American with Disabilities Act, this material is available in alternate formats. Please call (410) 767-3300, (800) 974-0203, or (800) 735-2258 (TTY/Voice). 12/10/2015

-----------------------

Maryland Higher Education Commission

Office of Student Financial Aid

6 N. Liberty Street, Ground Suite

Baltimore, MD 21201

(410) 767-3300; (800) 974-0203

TTY for the Deaf - (800) 735-2258

mhec.

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