CUNY Logo 2021–2022 Custom Verification Worksheet V4-Independent Student Your 2021–2022 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 could 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 must sign the Section B certification at the bottom of the page. 2. Collect the documents required for Section C on page 2 but do NOT complete that section in advance. 3. Submit the completed worksheet and any other required documents to the Financial Aid Office at your college. You will complete Section C in person at that time. A. Student’s Information Student’s Last Name First Name (Student’s Last Name First Name M.I.) Student’s Street Address (include apt. no.) (Student’s Street Address (include apt. no.)) City, State, Zip Code (City, State, Zip Code) Student’s Phone Number (include area code) (Student’s Phone Number (include area code)_Row_1) M.I. Student’s Social Security Number (Student’s Social Security Number) Student’s CUNYfirst ID / Empl ID (Student’s CUNYfirst ID / Empl ID) Student’s Date of Birth (Student’s Date of Birth) Student’s Email Address (Student’s Email Address) B. Certification and Signatures – Student must sign I/we certify that all the information reported on this worksheet is complete and correct. I/we understand that if we purposely give false or misleading information, we could be fined, jailed, or both. [If student is married, the spouse’s signature is optional.] Student Signature Date (Date_Row_1) Spouse Signature Date (Date Spouse Signed) Do not mail this worksheet to the U.S. Department of Education. Submit this worksheet to the Financial Aid Office at your college. 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. 2021-22 Custom Verification Worksheet V4-Independent Student Page 1 of 2 Student Name: (Student Name:) Student SSN: XXX-XX-____ ____ ____ ____ (Student SSN: Fourth from last digit) (Student SSN: third from last digit) (Student SSN: second from last digit) (Student SSN: last digit) 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) I certify that I, ___________________________________________________________________ (Print Name) 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 (Name of CUNY Institution Attending) ________________________________________________________________ for 2021-2022. (Name of CUNY Institution Attending) (Date) Student’s Signature: ___________________________________ Date: ____________________ 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 Type of Valid ID Collected (Date Received) (Type of Valid ID Collected) 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 (Date Received) 2021-22 Custom Verification Worksheet V4-Independent Student Page 2 of 2