Student Information (please print)

Last Name

First Name

Middle Initial

CSUN ID Number:

Educational Opportunity Program

EOP FINANCIAL VERIFICATION WORKSHEET 2014-2015 All EOP applicants whose household does not, and is not required to, file taxes must submit the following (check both): Verification Worksheet: Both you and a parent (if under 24, unmarried and with no dependent children) MUST sign this form. Documents Demonstrating Household Income: Most commonly statement of county or federal benefits. Review information about documents that meet this requirement at https://docs.google.com/document/d/1klAdlgL0revm_XIh8WY95z7LozFBztS0XnLiF5OnZCc/edit

If you answer questions on this worksheet using “N/A,” OR leave answers blank OR cross out responses it will DELAY your file from being processed. IF A QUESTION DOES NOT APPLY TO YOU OR YOUR PARENT(S) ANSWER $0. PLEASE DO NOT SUBMIT ORIGINAL DOCUMENTS! Need help filling out this form? Call our office at (818) 677-2351 or email us at [email protected]

A.

Student Contact Information

Address (Include Apt. No.)

City

State

Zip

Date of Birth B.

Phone Number (Include Area Code)

Family Information: List the following people in your household (even if they do not attend college): INCLUDE: 1. Yourself

Full Name (example) Missy Jones

2. Your parent(s)/stepparent

3. Your parents’ dependent children, unborn child*and others for whom they will provide more than 50% support

Age

Relationship

List Full Name of College

Enrolled 1/2 time or more

19

Sister

California State University, Northridge

YES

Self

California State University, Northridge

*Unborn child must be born before July 1, 2014 and you must submit a doctor’s note with the due date for any unborn child.

Student Name:

CSUN ID Number:

____________________________

If you answer questions on this worksheet using “N/A,” OR leave answers blank OR cross out responses it will DELAY your file from being processed. IF A QUESTION DOES NOT APPLY TO YOU, ANSWER $0. STUDENT INFORMATION C. Student Income: Please check one of the following boxes: I, the student, did not earn money in 2012. I, the student, earned money, but was NOT required to file to 2012 (or 2013) Federal Income Tax Return. Please list sources of income below List Sources of Income (Use the W-2 form or other earnings statements)

D.

2012 Amount

Employer Name:

$

Employer Name:

$

Total 2012 Income: (If you had more than two employers in 2012, please include a separate sheet)

$

Student Assets

Failure to respond to the questions below will delay your EOP application consideration process.

These questions apply to the student only; Parent(s) asset information is requested in section F.



What is the balance of your cash/savings/checking account(s)?

$__________________________



What is the net worth of your real estate & investments?

$__________________________

(Do not include the value of the home you live in)



What is the net worth of your business/investment farm?

$__________________________

PARENT INFORMATION (if under 24, unmarried with no dependent children and/or not former ward of the court/foster youth) E.

Parent Income: Please check one of the following boxes: I/We, the parent(s), did not earn money in 2012. I/We, the parent(s), earned money, but was/were NOT required to file to 2012 (or 2013) Federal Income Tax Return. Please list sources of income below List Sources of Income (Use the W-2 form or other earnings statements)

F.

2012 Amount

Employer Name:

$

Employer Name:

$

Total 2012 Income: (If you had more than two employers in 2012, please include a separate sheet)

$

Parent Assets Failure to respond to the questions below will delay your EOP application consideration process.

 What is the balance of your cash/savings/checking account(s)?

$__________________________

 What was the net worth of your real estate & investments at the time the FAFSA was filed?

$__________________________

(Do not include the value of the home you live in)  What was the net worth of your business/investment farm at the time the FAFSA was filed?

$__________________________

G. Parent Child Support Received. Please check one of the following boxes: I/We, the parent(s), received Child Support in 2012. (Please report the total amount of Child Support Received) I/We, the parent(s), did not receive Child Support in 2012.

$__________________________



__

Student Name:

CSUN ID Number:

____________________________

Student and Parent (if student is under 24, unmarried and/or with no dependent children, and not a ward of the court/former foster youth) MUST SIGN THIS WORKSHEET! Failure to sign appropriately will delay your EOP application consideration process. H. By signing this worksheet, we certify that all the information reported on it is complete and correct. At least one parent must sign. Student___________________________________________

Date____________________________________

Parent___________________________________________

Date_______________________________________________

RETURN THIS FORM AND Supporting Documents in person, by fax or scan & email to: In Person: EOP Admissions & Partnership Programs, Bayramian Hall Room 210 By Fax:

(818) 677-7728 (make sure to call to confirm receipt) By Email:

Questions?

[email protected]

Call us at (818) 677-2351.

We’re here to help!

EOP Financial Verification Form 2014-15.pdf

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