Financial Aid Office 1600 Maple Street Golden CO 80401 303-273-3220 303-384-2252 fax finaid@mines.

edu

2010-2011 Institutional Verification Form DO NOT LEAVE BLANKS USE ZERO IF APPLICABLE
Student: _______________________________________ Last First M.I. Campus Wide I.D.#:_____________________________

Your file has been selected for verification of the data provided on your Free Application for Federal Student Aid (FAFSA). Delays in completion and submittal of this form may result in limited funding for 2010-2011. ***If needed, we reserve the right to request additional documents that are not specified on this form*** STUDENT TAX FORM AND INCOME INFORMATION (Check One) I(We) have attached a complete and signed copy of my/our 2009 tax return (IRS Form 1040/1040A/1040EZ), including all schedules, statements and any applicable W-2 forms. I(We) was not required to file a 2009 tax return (IRS Form 1040/1040A/1040EZ). List any income received in 2009 (please attach verification of income i.e. W-2s, 1099-Misc., etc.) (if no income was received use $0) - $_________________________

PARENT TAX FORM AND INCOME INFORMATION (Check One) I(We) have attached a complete and signed copy of my/our 2009 tax return (IRS Form 1040/1040A/1040EZ), including all schedules, statements and any applicable W-2 forms. I(We) was not required to file a 2009 tax return (IRS Form 1040/1040A/1040EZ). List any income received in 2009 (please attach verification of income i.e. W-2s, 1099-Misc., etc.) (if no income was received use $0) - $_________________________

HOUSEHOLD/FAMILY INFORMATION FAFSA with parental data (dependent student): Complete the following information about your parents household. If you have two parental households, list only the members for the household referenced on the FAFSA. Include all of the following individuals in your parents household, even if they will not attend college during the 2010-11 academic year: Parent(s) Step-Parent Dependent Sibling(s) FAFSA without parental data (independent student): Complete the following information about your household. Include all of the following: Spouse Dependent Children
Relationship to student (parent, brother/sister, etc.) SELF This person will attend college half-time or more in 2010-2011 YES NO Print the name of the college and the degree program the student is pursuing (i.e. B.A., B.S., PhD) Colorado School of Mines

Name

Age

1. CSM STUDENT:

2. 3. 4. 5. 6.

Campus Wide I.D.#:______________________________ STATEMENT OF RESOURCES/ALLOWABLE DEDUCTIONS 2009 RESOURCES/UNTAXED INCOME Child Support received (do not include foster care or adoption payments) Welfare benefits incl. Temporary Assistance for Needy Families (TANF) (dont include food stamps) Housing, food, and other living allowances paid to members of the military, clergy and others Veterans non-education benefits Any other untaxed income and benefits not reported elsewhere on this form Cash received or money paid on your behalf not reported elsewhere on this form (do not include educational expenses) List source/s: ________________________________________________________ Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including, but not limited to, amounts report on the W-2 forms in Boxes 12a through 12d, codes D, E, F, G, H and S. ALLOWABLE DEDUCTIONS Child support paid because of divorce or legal separation Taxable earnings from Federal/State Work-Study or other need-based work programs Earnings from work under a cooperative education program offered by a college. Student grant and scholarship aid (in excess of tuition, fees, and books) that was reported to the IRS ASSET VERIFICATION Report all values as of the date the FAFSA was completed. Attach additional pages if necessary. Net worth of business, corporation or partnership Net worth of farm or ranch (do not include if family lives on the property) Net worth of rental property/ies By signing below, I(we) certify that all the information reported on this worksheet is complete and correct. At least one parent must sign (for dependent students). WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both. Student_____________________________ Date___________ Parent _______________________Date____________ Student Annual Totals Parent Annual Totals Student Annual Totals Parent Annual Totals

Student Annual Totals

Parent Annual Totals