2017–2018 Custom Verification Worksheet 
V4-Independent Student 


Your 2017–2018 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 M.I. Student’s Social Security Number 
(Student’s Last Name First Name M.I._Row_1) 
(Student’s Social Security Number_Row_1) 
Student’s Street Address (include apt. no.) Student’s CUNYfirst ID / Empl ID 
(Student’s Street Address (include apt. no.)_Row_1) 
(Student’s CUNYfirst ID / Empl ID_Row_1) 
City, State, Zip Code Student’s Date of Birth 
(City, State, Zip Code_Row_1) 
(Student’s Date of Birth_Row_1) 
Student’s Phone Number (include area code) Student’s Email Address 
(Student’s Phone Number (include area code)_Row_1) 
(Student’s Email Address_Row_1) 


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_Row_1) 


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. 

2017-18 Custom Verification Worksheet V4-Independent Student Page 1 of 2 


Student Name: 
(Student Name:) 
Student SSN: XXX-XX- ____ ____ ____ ____ 
(Student SSN: XXX-XX) 
(undefined) 
(undefined) 
(undefined) 


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) 

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 

________________________________________________________________ for 2017-2018. 
(Name of CUNY Institution Attending) 

Student’s Signature: ___________________________________ Date: ____________________ 

OFFICE USE ONLY- DO NOT WRITE BELOW 
1. Proof of Identity 
The above-named student has presented valid government-issued photo identification such as a 
state driver’s license, non-driver’s license or passport which verifies his or her identity. 

FA Certifying Officer’s Signature 

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 

2017-18 Custom Verification Worksheet V4-Independent Student Page 2 of 2