Dependent Income Verification Form
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2Office of Student Financial Services
98 Bridge Street
Henniker, NH 03242
603.428.2226 | sfs@nec.edu
2017-2018 Dependent Income Verification Form
Student Name:
Student NEC ID#:
– STUDENT and/or PARENT INFORMATION
SECTION A
. The
Your 2017–2018 Free Application for Federal Student Aid (FAFSA) was selected for review in a process called verification
student and parent(s) must provide all of the information requested on this form and return this document to the Student
Financial Services Office. Please Note: Complete all sections of this form, if any spaces are left blank, this form will be
considered incomplete and returned for completion. Additional documentation may be requested by our office upon receipt
of this completed form.
1. Was the student required to file taxes in 2015?
Yes
No
2. Was the student’s parent(s) required to file taxes in 2015?
Yes
No
3. Did the student and/or parent(s) receive 2015 Income Earned from Work?
Yes (If yes, please attach ALL copies of 2015 Employer W2’s)
No
4. Did the student and/or parent(s) receive any untaxed income in 2015?
Yes (If yes, please check all that apply in section B and indicate the monthly amount received)
No (Please skip section B and go to Section C)
– INCOME and BENEFITS
SECTION B
If you received any benefits for less than a 12 month period, please specify the
number of months in column provided below.
Was this benefit
Monthly
Who received this
Was this benefit received
Monthly Benefit
received by anyone
Amount?
benefit?
for 12 months in 2015?
you listed in your
household?
Self
Social Security Income:
Yes
No
Yes
No
(Retirement, Survivor,
Relative/Parent
Disability, Supplemental etc.)
If no, indicate number of
Other:
$
months:
Self
Fuel Assistance:
Yes
No
Yes
No
Relative/Parent
If no, indicate number of
Other:
$
months:
Self
AFDC/TANF and/or
Yes
No
Yes
No
Housing Subsidies:
Relative/Parent
If no, indicate number of
Other:
$
months:
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