2021-2022 Student Verification Worksheet

To be submitted when requested by Student Financial Services

Name Name First Last
Email
I know my Simmons ID number:

I know my Simmons ID number: Yes No
Simmons ID
Address Address
Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country
Phone Phone - ### - ### ####
Date of Birth Date of Birth / MM / DD YYYY
Program Information 2021-2022
Academic Level

Academic Level Undergraduate Graduate
Student Type

Student Type Traditional Undergraduate Transfer Student Dix Scholar CompleteDegree@Simmons
Program Type

Program Type On Campus Online Behavior Analysis Online Library Science Online MBA/HCMBA Online Nursing Online Public Policy Online Social Work
Dependency Status
According to your FAFSA, are you an independent or dependent student?

According to your FAFSA, are you an independent or dependent student? Dependent Independent

If you were required to report your parents' information on the FAFSA, then you are considered a dependent student.
Please indicate your marital status

Please indicate your marital status Single Married Separated/Divorced
2019 Student Tax Return Filing Status
Please indicate below whether you, the student (or your spouse) filed a 2019 tax return.

Please indicate below whether you, the student (or your spouse) filed a 2019 tax return. Yes, I filed a 2019 U.S. federal tax return. I have/will complete the IRS Data Retrieval process to upload my tax information directly from the IRS into my FAFSA. No, I did NOT file a 2019 federal tax return.
If you did NOT file a 2019 U.S. federal tax return, indicate whether you were employed in 2019.

If you did NOT file a 2019 U.S. federal tax return, indicate whether you were employed in 2019. I (and/or my spouse, if applicable) was not employed and had no income earned from work in 2019. I (and/or my spouse, if applicable) was employed in 2019, but I was not required to file a federal tax return.
List all work income below and attach copies of all 2019 W-2 forms. If you had more than three employers, please provide the additional information via an email to [email protected].

Employer Name
2019 Amount Earned $ Dollars . Cents
Attach W-2 Form

Attach Files

Please remove your SSN from the document prior to uploading or emailing.
+Add

+Add Add another source of work income
Employer Name
2019 Amount Earned $ Dollars . Cents
Attach W-2 Form

Attach Files

Please remove your SSN from the document prior to uploading or emailing.
+Add

+Add Add another source of work income
Employer Name
2019 Amount Earned $ Dollars . Cents
Attach W-2 Form

Attach Files

Please remove your SSN from the document prior to uploading or emailing.
Household Members

List the people in your or (if dependent) your parents'/custodial parent's household. If you need to list more than five people, please provide the additional information via an email to [email protected]. Include:

You, the student.

Your parent(s), OR custodial parent and stepparent, who provide half of your support even if you don't live with them.

Your parents’ other children if your parent will provide more than half of the child's support from July 1, 2021 – June 30, 2022, or if the other children would be required to provide parental information if they were completing a FAFSA for 2021-2022.

Other people if they now live with your parent(s) and your parent(s) provide more than half of the other person's support and will continue to provide more than half of their support through June 30, 2022.

Provide college information for students enrolled at least half-time during 2021-2022 in a program leading to a degree, diploma, or certificate.
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete

We see you only included one person in your household. Is this accurate? Dependent students cannot be the only member in the household.

If accurate, please indicate that your list is complete.
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
+Add

+Add Add another household member Household member list is complete
Full Name Full Name First Last
Date of Birth Date of Birth / MM / DD YYYY
Relationship
Enrolled in college during 2021-2022?

Enrolled in college during 2021-2022? Yes No
Name of Institution in 2021-2022
Expected Graduation Date
Do you have more household members to add?

If you have any additional household members that will not fit on this form, please email their information to [email protected].
Retirement Rollover
Did you, the student, roll over a retirement account in 2019?
Did your parent(s) roll over a retirement account in 2019?
Parent name:
If yes, please provide a copy of your 2019 1040 form with the annotation of a rollover.

Attach Files

Please remove your SSN from the document prior to uploading.
Requested Information

Please check the items below for which Student Financial Services has requested additional information. If none of these items were specifically requested, please select N/A.
Check all that apply:

Check all that apply: Assets Child Support SNAP Benefits Untaxed Income N/A

Please only provide information if it has been requested by our office.
Asset Information

The information reported here should reflect asset levels as of the date your FAFSA was originally filed.
Student's Cash/Checking/Savings $ Dollars . Cents
Student's Investments $ Dollars . Cents
Includes stocks, bonds, and real estate (excluding primary residence/home).
Student's Business Value $ Dollars . Cents
Exclude any family business with 100 or fewer full-time employees.
Parents' Cash/Checking/Savings $ Dollars . Cents
Parents' Investments $ Dollars . Cents
Includes stocks, bonds, and real estate (excluding primary residence/home).
Parents' Business Value $ Dollars . Cents
Exclude any family business with 100 or fewer full-time employees.
Child Support

One ore more members of your household either paid or receive child support in 2019.
Name of Child for Whom Support Was Paid

If SFS has reason to believe that the information regarding child support is not accurate, we may require additional documentation such as a signed statement from the recipient or fiancial records reflecting the payments.
Name of Person Who Paid Child Support
Name of Person Who Received Child Support
Amount of Child Support Paid in 2019 $ Dollars . Cents
+Add

+Add Add a child for whom support was paid All child support information has been provided
Name of Child for Whom Support Was Paid
Name of Person Who Paid Child Support
Name of Person Who Received Child Support
Amount of Child Support Paid in 2019 $ Dollars . Cents
+Add

+Add Add a child for whom support was paid All child support information has been provided
Name of Child for Whom Support Was Paid
Name of Person Who Paid Child Support
Name of Person Who Received Child Support
Amount of Child Support Paid in 2019 $ Dollars . Cents
+Add

+Add I will email [email protected] if I need to document any further child support All child support information has been provided
Certification of SNAP Benefits

SNAP, or the Supplemental Nutrition Assistance Program, may be known by another name in some states. For assistance in determining the name used in your state, please call 1-800-433-3243.
I certify:

I certify: that a member of my/my parents' household received SNAP benefits sometime during 2019 and/or 2020. that the information provided on my FAFSA was incorrect and that no one in my household received SNAP benefits during 2019 and/or 2020.
Attach a copy of the 2019 or 2020 statement of benefits received from SNAP

Attach Files

If applicable, please remove your SSN from the document prior to uploading or emailing.
Untaxed Income

Information listed here is to be reported for both the student and the parents (if applicable).
Student's payments to tax-deferred pension and savings plans: $ Dollars . Cents
See W-2 forms (boxes 12a through 12d with codes D,E,F,G,H, and S)
Student's IRA deductions and SEP/SIMPLE payments: $ Dollars . Cents
See IRS Forms 1040, Schedule 1 (line 15 + line 19).
Student's tax exempt interest income: $ Dollars . Cents
See IRS Forms 1040 (line 2a).
Student's untaxed portions of IRA distributions and pensions: $ Dollars . Cents
IRS Forms 1040 (lines 4a + 4c) minus (lines 4b + 4d). Exclude rollovers.
Student's housing, food, and other living allowances paid to members of military, clergy, others. (do not include value of on-base housing or basic living allowance): $ Dollars . Cents
Student's non-educational veterans benefits, such as Death Pension or Dependency & Indemnity Compensation (DIC): $ Dollars . Cents
Any other untaxed income/benefits for the student: $ Dollars . Cents
Parents' payments to tax-deferred pension and savings plans: $ Dollars . Cents
See W-2 forms (boxes 12a through 12d with codes D,E,F,G,H, and S)
Parents' IRA deductions and SEP/SIMPLE payments: $ Dollars . Cents
See IRS Forms 1040 Schedule 1 (line 15 + line 19)
Parents' tax exempt interest income: $ Dollars . Cents
See IRS Forms 1040 (line 2a).
Parents' untaxed portions of IRA distributions and pensions: $ Dollars . Cents
IRS Forms 1040 (lines 4a + 4c) minus (lines 4b + 4d). Exclude rollovers.
Parents' housing, food, and other living allowances paid to members of military, clergy, others. (do not include value of on-base housing or basic living allowance): $ Dollars . Cents
Parents' non-educational veterans benefits, such as Death Pension or Dependency & Indemnity Compensation (DIC): $ Dollars . Cents
Any other untaxed income/benefits for the parent(s): $ Dollars . Cents
Spouse's payments to tax-deferred pension and savings plans: $ Dollars . Cents
See W-2 forms (boxes 12a through 12d with codes D,E,F,G,H, and S)
Spouse's' IRA deductions and SEP/SIMPLE payments: $ Dollars . Cents
See IRS Forms 1040 Schedule 1 (line 15 + line 19)
Spouse's tax exempt interest income: $ Dollars . Cents
See IRS Forms 1040 (line 2a).
Spouse's untaxed portions of IRA distributions and pensions: $ Dollars . Cents
IRS Forms 1040 (lines 4a + 4c) minus (lines 4b + 4d). Exclude rollovers.
Spouse's housing, food, and other living allowances paid to members of military, clergy, others. (do not include value of on-base housing or basic living allowance): $ Dollars . Cents
Spouse's non-educational veterans benefits, such as Death Pension or Dependency & Indemnity Compensation (DIC): $ Dollars . Cents
Any other untaxed income/benefits for your spouse: $ Dollars . Cents
Signatures and Certifications

Please read this section carefully.
Please acknowledge by checking each box

Please acknowledge by checking each box I understand that by signing this form that all information provided is complete and correct to the best of my knowledge. I authorize Simmons to update my FAFSA to reflect the information provided here. I understand that in order to be awarded financial aid, I must submit a 2021-2022 FASFA (fafsa.gov) and may be asked to supply additional information to SFS. (e.g., Federal Income Tax Return Transcript and W-2’s). I understand that omitting or misreporting information on this form may result in a change or delay to my financial aid award. I understand that if there is any change in the information provided on this form I must notify SFS in writing and that my financial aid award may be revised. I understand if I do not notify SFS of changes to my enrollment, my actual enrollment will be reviewed at the end of the add/drop registration period and my financial aid will be adjusted at that time, if necessary. I understand that by signing this form, my (and my family’s) financial and/or academic information may be shared with outside agencies for the purpose of processing any benefit I may receive from those agencies. I understand that if I receive a scholarship, grant, or benefit (e.g., military, disability, or employer) from any source outside of Simmons, I am required to notify Student Financial Services by submitting a copy of the letter or certificate from the agency. As the parent of a dependent undergraduate student, I authorize any Title IV federal aid in my name to be applied against all charges on my student's account. If I wish to revoke this authorization or learn more, I will review the FAQ available on Simmons' website.
Student Name
Date Date / MM / DD YYYY
Student Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Parent Name
(one of the parents listed on the FAFSA's signature is required for financially dependent undergraduate students)
Date Date / MM / DD YYYY
Parent Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Type the letters you see in the image below.

2021-2022 Student Verification Worksheet

2021-2022 Student Verification Worksheet

Program Information 2021-2022

Dependency Status

2019 Student Tax Return Filing Status

Household Members

Do you have more household members to add?

Retirement Rollover

Requested Information

Asset Information

Child Support

Certification of SNAP Benefits

Untaxed Income

Signatures and Certifications