2021-2022 Household Verification Worksheet

Student Name Student Name First Last
Student 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
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].
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 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.
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 Household Verification Worksheet

2021-2022 Household Verification Worksheet

Program Information 2021-2022

Dependency Status

Household Members

Do you have more household members to add?

Signatures and Certifications