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2020–2021 Custom Verification Worksheet 
V4-Dependent Student 

Your 2020–2021 Free Application for Federal Student Aid (FAFSA) was selected for review in a 
process called “Verification”. The Financial Aid Office at your college must compare information 
from your FAFSA with information you provide on this worksheet and with any other required 
documents. If there are differences, your Financial Aid Office may require additional 
documentation and your FAFSA information may need to be corrected. You will not receive federal 
financial aid until all verification requirements are met and the necessary corrections made. 

What You Should Do 

1.Complete Section A of this worksheet – you and one of your parents must sign the SectionB certification at the bottom of the page.
2.Collect the documents required for Section C on page 2 but do NOT complete that section inadvance.
3.Submit the completed worksheet and any other required documents to the Financial AidOffice at your college. You will complete Section C in person at that time.


A.Student’s Information

Student’s Last Name First NameM.I.
(text) 


Student’s Street Address (include apt. no.) 
(text) 


City, State, Zip Code 
(text) 


Student’s Phone Number (include area code) 
(text) 


Student’s Social Security Number 
(text) 


Student’s CUNYfirst ID / Empl ID 
(text) 


Student’s Date of Birth 
(text) 


Student’s Email Address 
(text) 


B.Certification and Signatures – Student and one parent must sign

We certify that all of the information reported on this worksheet is complete and correct. Weunderstand that if we purposely give false or misleading information, we could be fined, jailed,
or both.

Student Signature 

Date 
(text) 


Parent Signature 

Date 
(text) 


Do not mail this worksheet to the U.S. Department of Education. 
Submit this worksheet to the Financial Aid Office at your c ollege. 
You should make a copy of this worksheet and all submitted documents for your records. 
You must complete Section C on page 2 of this worksheet IN PERSON at the Financial Aid 
Office at your college. 

2020-21 Custom Verification Worksheet V4-Dependent Student Page 1 of 2 


Student Name: 
(text) 


Student SSN: XXX-XX-____ ____ ____ ____ 
(text) 
(text) 
(text) 
(text) 


C.Identity Verification and Statement of Educational Purpose

Do not complete this page in advance. You must complete and sign this page IN PERSON 
at the Financial Aid Office at your college. 

You have been selected by the U.S. Department of Education to verify your identity and 
educational plans. You must appear in person at the Financial Aid Office at your college and 
present a piece of valid government-issued identification to a financial aid representative. The 
representative will review and copy this piece of identification which will be maintained in your 
student file. 

Statement of Educational Purpose 

I certify that I, ___________________________________________________________________ 
(Print Name) 
(text) 


am the individual signing this Statement of Educational Purpose and that the federal student 
financial assistance I may receive will only be used for educational purposes and to pay the cost of 
attending 
(text) 
for 2020-2021. 
(Name of CUNY Institution Attending) 

Student’s Signature: ___________________________________ Date: ____________________ 
(text) 


OFFICE USE ONLY-DO NOT WRITE BELOW 

1.Proof of Identity

The above-named student has appeared in person and presented an unexpired valid government 
issued photo identification such as, but not limited to, a state driver’s license, non-driver’s 
identification card, other State-issued identification, or U.S. passport which verifies his or her 
identity. 

NOTE: An unexpired valid government-issued photo identification is one issued by the U.S. 
government, any of the 50 States, the District of Columbia, the Commonwealth of Puerto Rico, a 
federally recognized American Indian and Alaska Native Tribe, or other U.S. territory as outlined in 
the Federal Register. 

FA Certifying Officer’s Signature 

Date Received 
(Date Received ID) 


Type of Valid ID Collected 
(text) 


2.Completion of High School or the Equivalent

The above-named student has submitted a final high school transcript or other acceptable 
documentation to the appropriate CUNY office that shows evidence of graduation from an 
accredited high school or educational institution, state-issued general education equivalency (GED), 
or evidence of home schooling. 

FA Certifying Officer’s Signature 

Date Received 
(text) 


2020-21 Custom Verification Worksheet V4-Dependent Student Page 2 of 2