uc santa cruz

FINANCIAL AID AND SCHOLARSHIP OFFICE 

uc santa cruz 

13DEPSTPKT 

UCSC Student’s ID /Account 

Number (Do not use CRUZ ID) 

UCSC Student’s Last Name 

First Name 

2012–2013 Dependent Student Verification Packet 

You have been selected by the UC Santa Cruz Financial Aid and Scholarship Office for a process called “verification”. In this process, 

we will compare information you provided on the FAFSA with information you provide in this packet. If necessary, we will make 

corrections and update your FAFSA. 

Priority Due Date: June 15, 2012 

Submit the completed and signed forms to: 

UC Santa Cruz 

Financial Aid and Scholarship Office 

205 Hahn Student Services Building 

1156 High Street 

Santa Cruz, CA 95064 

To protect your personal information, do not send completed forms via e-mail. If you have questions about the information 

contained in this packet, please contact us at 831-459-2963. 

Use the checklist below before mailing your information to avoid delays: 

q Federal Tax Returns (Do not send your state return.) Be sure the return is signed. 

Attach signed copies of your 2011 1040,1040A, or 1040EZ IRS federal tax return along with all schedules and attachments — 

include all pages. If you file an IRS tax extension, do not submit this packet. Submit the 2012–2013 Tax Extension Packet for 

Dependent Student. 

q W-2 and/or 1099 Forms 

Include all 2011 W-2 and/or 1099 forms received from your employer(s) if applicable. 

q Signatures 

Signatures are required on the tax return and the certification found on the last page of this packet. 

q Answer All Questions 

Answer every question. DO NOT LEAVE BLANKS. If something does not apply to you, respond using “N/A” (not 

applicable) or a “0” (zero). A blank answer will mean the information is incomplete and you will be asked to complete a 

new packet which may delay your eligibility for financial aid. 

Page 1 of 5 You must complete all pages of this packet F3DPKT

FINANCIAL AID AND SCHOLARSHIP OFFICE 

uc santa cruz 

13DEPSTPKT 




2012–2013 Dependent Student Verification Packet 

First Name 

1. Print the student’s name and ID/account number clearly at the top of all pages of this packet. 

2. The parent and student who provided the FAFSA information must complete and sign the Certification on page 5. 

3. The parent and student must answer all questions. IF THE ANSWER IS ZERO, OR IS NOT APPLICABLE, WRITE IN A “O”. DO NOT LEAVE BLANKS. 

Student living arrangements during the 2012-13 academic year (check one): 

q On Campus q Off Campus q With parent(s) q Undecided 

Federal Tax Returns and Income Information 

STUDENT 

q A complete, signed copy of my 2011 IRS federal income tax return is attached (including schedules and attachments). 

q I will not file a 2011 IRS federal income tax return. Please report wages earned and business income below. 

q Wages earned during 2011 from work 

q Net business income 

$____________ 

Do Not Leave Blank 

$____________ 


q Do you own and control more than 50% of a business with over 100 employees? q yes 

q no 

PARENT 

q A complete, signed copy of my 2011 IRS federal income tax return is attached (including schedules and attachments). 

q I will not file a 2011 IRS federal income tax return. Please report wages earned and business income below. 

q Wages earned during 2011 from work by $_______________ Do Not Leave Blank father/stepfather 

$_______________ Do Not Leave Blank mother/stepmother 

q Net business income earned by 

$_______________ Do Not Leave Blank father/stepfather 

$_______________ Do Not Leave Blank mother/stepmother 

q Do you own and control more than 50% of a business with over 100 employees? q yes q no 

In 2010 or 2011, did you or anyone in your household receive benefits from any of the Federal programs listed? Mark all programs that apply: 

q Supplemental Security Income q Food Stamps (SNAP) q Free or reduced price lunch q TANF q WIC 

other Income Information 

PARENT 

STUDENT 

1. Child support received by you for any of your children. Don’t include foster care or adoption payments. $____________/yr. Do Not Leave Blank $____________ N/A 

2. Housing, food, and other living allowances paid to members of the military, clergy and 

others (including cash payments and cash value of benefits). Don’t include the value of 

on-base military housing or the value of a basic military allowance for housing. $____________/yr. Do Not Leave Blank $____________/yr. 


3. Veterans noneducation benefits, such as Disability, Death Pension, or Dependency & 

Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances. $____________/yr. Do Not Leave Blank $____________/yr. 


4. Other untaxed income not reported such as workers’ compensation, disability, etc. Do not 

include student aid, earned income credit, additional child tax credit, welfare payments, untaxed 

Social Security Benefits, Supplemental Security Income, Workforce Investment Act educational 

benefits, combat pay (if you are not a tax filer), benefits from special spending arrangements 

(e.g. cafeteria plans), foreign income exclusion, or credit for federal tax on special fuels. $____________ Do Not Leave Blank $____________/yr. 


5. Money received or paid on your behalf (e.g. bills) not reported elsewhere on this form. $____________/yr. N/A 

$____________/yr. 


Do not include financial aid. Please state source: _____________________________________ 





First Name 

other Income Information continued PARENT STUDENT 

6. Child support paid by you because of divorce or separation or as a result of a legal requirement. 

Don’t include support for children in your household. 

List names _______________________________________________________________ $____________/yr. Do Not Leave Blank $____________/yr. 

N/A 

7. Taxable earnings from need-based employment programs, such as Federal Work-Study and 

need-based employment portions of fellowships and assistantships. $____________/yr. Do Not Leave Blank $____________/yr. 


8. Taxable student grant and scholarship aid reported to the IRS in your adjusted gross income. 

Includes AmeriCorps benefits (awards, living allowances and interest accrual payments), as 

well as grant and scholarship portions of fellowships and assistantships. $____________/yr. Do Not Leave Blank $____________/yr. 


9. Combat pay or special combat pay. Only enter the amount that was taxable and included 

in your adjusted gross income. Do not enter untaxed combat pay. 

10. Earnings from work under a cooperative education program offered by a college. 

$____________/yr. Do Not Leave Blank 

$____________/yr. Do Not Leave Blank 

$____________/yr. 


$____________/yr. 


Savings, Investments and Other Assets on the Date the FAFSA was Filed 

Note: Investments do not include the home you live in, the value of life insurance, retirement plans (pension funds, 

annuities, non-education IRA’s, Keogh plans, etc.) 

PARENT 

STUDENT 

Cash, Savings and Checking Accounts $____________________ Do Not Leave Blank 

$____________________ 


Trust Funds $____________________ Do Not Leave Blank 

$____________________ 


UGMA/UTMA Accounts $____________________ Do Not Leave Blank 

$____________________ 


Money Market $____________________ Do Not Leave Blank 

$____________________ 


Mutual Funds $____________________ Do Not Leave Blank 

$____________________ 


Certificates of Deposit $____________________ Do Not Leave Blank 

$____________________ 


Stock $____________________ Do Not Leave Blank 

$____________________ 


Stock Options $____________________ Do Not Leave Blank 

$____________________ 


Bonds, other securities $____________________ Do Not Leave Blank 

$____________________ 


Installment and Land Sale Contracts $____________________ Do Not Leave Blank 

$____________________ 


Other (specify)_____________________________ $____________________ Do Not Leave Blank 

$____________________ 


Educational Benefits $____________________ Do Not Leave Blank 

$____________________ 

N/A 

Educational Savings Accounts $____________________ Do Not Leave Blank 

$____________________ 

N/A 

529 College Savings Accounts for all family members $____________________ Do Not Leave Blank 

$____________________ 

N/A 

Refund Value of 529 Prepaid Tuition Plans $____________________ Do Not Leave Blank 

$____________________ 

N/A 

For Office Use Only: 

Total Investments ____________________ ____________________ 





First Name 

Parent Real Estate Investments 

Does your parent own real estate investments excluding the home you live in? q Yes q No 

If yes, provide details below. 

Complete this information for all real estate you own other than the home you live in, such as mobile homes, condos, duplexes, 

rental property, land, summer homes, etc, as of the date the 2012-13 FAFSA was filed. 

Property 1 (Do not report the home you live in): 

Current Market Value* $ ____________ Mortgage Balance $ ____________ Purchase Price $ ____________ Year Acquired _______ 

Property Address _______________________________________________________________________________________________ 

Street address City State Zip Code 









Complete this section if you, the parent, RENTED OUT A PORTION OF THE HOME YOU LIVE IN that meets the following criteria: 

the rental unit has its own entry and includes a kitchen and bath. The portion of your home that generates rental income is 

considered an asset and must be reported as an investment net worth on the FAFSA. Complete the following information about 

the home you live in: 

Current Market Value* $ ___________ Mortgage Balance $ ___________ Purchase Price $ ___________ Year Acquired ______ 

Rental Square Footage ___________ + Home Square Footage ___________ = Total Dwelling Square Footage ___________ 

*on the date you filed the FAFSA 

Student Real Estate Investments 

Does the student own any real estate investment property q yes 

q no 

For Office Use Only 

Total Current Market Value _______________ – Total Mortgage Balance ________________ = Real Estate Net Worth_____________ 

Total Investments_________________ + Real Estate Net Worth _______________ =Total Investment Net Worth_________________ 





First Name 

Household Information 

List the people in your household. Include yourself, your spouse, and your children, if (a) you provide more than half of their support or (b) the 

children would be required to provide parental information when applying for Federal Student Aid. List any other people if they now live with 

you and you provide more than half of their support and will continue to provide more than half of their support from July 1, 2012 through June 

30, 2013. If you have additional people to list, attach a separate sheet of paper with the required information. 

Full Name of Family 

Member in Household 

Date 

of Birth 

MM/DD/YY 

Age 

Relationship 

to Student 

Social Security Number 

Name of College 

(if attending in 

2012–2013) 

For those enrolled in 

college for 2012–13, 

list current degree 

objective.* 

Father/ 

Stepfather 

Mother/ 

Stepmother 

UCSC 

Student 

self 

– – 

– – 

– – 

UCSC 

Other 

Members in 

Household 

– – 

– – 

– – 

– – 

*AA, BA, BS, Certificate, MA, PhD, MD, DDS 

In 2010 or 2011, did you receive federal low-income housing such as HUD or Section 8? q Yes q No 

CERTIFICATION 

• I hereby declare that all information reported on this document is true, complete, and accurate to the best of my knowledge. 

• I understand that any false statement or misrepresentation will be cause for denial, reduction, cancellation and/or repayment of financial aid. 

• I understand that verifications of enrollment will be required if family members are listed in college. 

• This document must be received no later than June 15, 2012 to meet the priority deadline for all types of financial aid. 

Parent, please report your marital status as of the date you submitted the 2012-2013 Fafsa application. Please provide the month and year 

you were married, separated, divorced, widowed, or a California Registered Domestic Partner in the box next to your selection. 

Single 

Divorced 

Separated 

Month Year 

Month Year 

Married/Remarried 

Widowed 

Month 

Month 

Year 

Year 

California Registered Domestic Partner 

Month 

Year 

Parent Signature _________________________________________ Date ___/____/_____ Parent Name__________________________________ 

please print 

Parent Phone ( _______ ) ________________________________ Parent E-mail Address ________________________________________________ 

Student Signature ______________________________________________________ Date ____/_____/______ 

Return to: UC Santa Cruz Financial Aid and Scholarship Office, 205 Hahn Student Services Building, 1156 High Street, Santa Cruz, CA 95064 

Phone: (831) 459-2963 Web: financialaid.ucsc.edu. For your protection and security, please do not e-mail forms.

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