FINANCIAL AID & SCHOLARSHIP OFFICE
1000 East Victoria Street
Carson, California 90747
PHONE: (310) 243-3691
CSUDH ID: Today s Date:
Financial Aid Document Submission Cover Sheet
Please complete the information requested below, submit this form along with your documents.
REMINDER: When uploading your documents to the online Dropbox, please exercise caution when using
Free WiFi or Public Computers as these are not secure.
Student Name:
Enter Last Name, First Name, MI
Toro Email Address:
Phone Number:
(Area Code) (i.e. 222-1234)
Note: Please be sure to include your CSUDH student ID number on each page submitted and allow up to 4
business days for your To Do List to be updated.
SUBMISSION INSTRUCTIONS:
On the following page(s), complete all requested information using the fillable document below. Your
document must be complete to be accepted by the Financial Aid & Scholarship Office. Forms that are
incomplete will remain on your To-Do-List in the Student Center.
1. Upon completing this document, scroll to the bottom where you are asked to sign and date. In the signature
area, type or sign your name and in the date space type today’s date.
2. Save your document and be sure to include your name and CSUDH Student ID# within the file name.
3. If you have attachments, please have them ready to upload to the online Dropbox
4. Return to the Financial Aid Forms page > go to the blue Dropbox Folders section > select the icon that
corresponds with your last name > use the “Add Files” or “drag and stuff here” option to upload your
documents. Emailed documents will not be accepted.
5. Once all documents have been submitted, be sure to close your browser.
In furtherance of CSU Dominguez Hill’s mission of accessibility and commitment to excellence through diversity, equity, and
inclusion, CSUDH strives to ensure that its information and communication technology is accessible to everyone. If you need
assistance in completing this form because of a disability, please contact us at (310) 243-3660
FINANCIAL AID & SCHOLARSHIPS OFFICE
1000 East Victoria Street
Carson, California 90747
(310) 243-3691
Student’s Name:
CSUDH ID#:
2023-2024 Dependent Verification Form
Your 2023-2024 Free Application for Federal Student Aid (FAFSA) or California Dream Act Application (CADAA) was
selected by the federal/state processor for secondary review in a process called verification. Applications are randomly
selected and you are asked to validate the information provided on your application is accurate. CSUDH will compare
your FAFSA or CADAA data with the information on this form and with any other submitted documents. If there are any
differences, CSUDH may need to correct information on your application.
•
You and at least one parent must complete and sign this form
•
Submit electronically to the Financial Aid Dropbox located at https://www.csudh.edu/financial-aid/forms/
•
Emailed documents will not be accepted
A.
DEPENDENT STUDENT’S FAMILY INFORMATION
List the people in your parent(s) household. Include:
■
Yourself;
■
Your parent(s) listed on the FAFSA or CADAA (including a stepparent if parent is remarried);
■
Your sibling(s), as long as your parent(s) will provide more than half of their support from July 1, 2023 - June 30, 2024,
or if your sibling(s) would be required to provide parental information if they were completing a FAFSA or CADAA for
2023-2024, even if they do not live with your parent(s); and
■
Other people if they now live with your parent(s) and your parent(s) provide more than half of the other person’s
support, and will continue to provide more than half of that person’s support through June 30, 2024.
Full Name
Age
Relationship
Will be
enrolled at
least half time
(Yes/No) *
College *
Self
Yes
CSU Dominguez Hills
*Include the name of college for any listed household member, excluding the parents, and if he/she is, or will be,
enrolled at least half time in a degree, or undergraduate certificate program at an eligible postsecondary
educational institution any time between July 1, 2023 and June 30, 2024. Additional documentation may be
requested if we have reason to believe that the information regarding the household member enrolled in the
eligible postsecondary educational institution is inaccurate.
If more space is needed, attach a separate page with your name and student ID number at the top.
Updated 02212023
FVRD24
Student’s Name: CSUDH ID#:
B.
STUDENT’S INCOME INFORMATION (Check only ONE response)
I, the student, have used the IRS Data Retrieval Tool (DRT) in FAFSA on the Web to transfer MY 2021
U.S. Individual Income Tax Return (Form 1040) information into my FAFSA.
I, the student, have filed and am unable to or choose not to use the IRS DRT in FAFSA on the Web and have
instead attached a signed copy of MY 2021 U.S. Individual Income Tax Return (Form 1040) with all schedules.
I, the student, was not employed and had no income earned from work in 2021.
I, the student, was employed and was not required by federal law to file a 2021 income tax return. I have listed
below the names of all employers and the amount earned from each employer in 2021. I have attached copies of
all 2021 W-2 form(s) I received from my employer(s).
Employer’s Name
If more space is needed, attach a separate page with your name and student ID number at the top.
C.
PARENT(s) INCOME INFORMATION
If two parents (married or unmarried and both parents are living together) were listed in Section A of this form, the
instructions and certifications below apply to both parents. Check and complete all applicable boxes IF parents
are unmarried and living together or if they have separate tax filing statuses for 2021.
My parent(s) have used the IRS Data Retrieval Tool (DRT) in FAFSA on the Web to transfer their 2021 U.S.
Individual Income Tax Return (Form 1040) information into my FAFSA.
My parent(s) have filed and attached a signed copy of their 2021 U.S. Individual Income Tax Return (Form 1040)
with all schedules to this form.
My parent(s) were not required by federal law to file a 2021 income tax return with the IRS.
Please submit ONE of the following documents and complete the table on the next page.
IRS Verification of Non-Filing Letter (dated on or after October 1, 2022)
➢
Request for FREE online at: www.irs.gov – Click on “Get Your Tax Record” then select “Get
Transcript ONLINE” or “Get Transcript by MAIL.” Make sure to request the “Verification of Non-Filing
Letter.”
2023-2024 Non-Filing Letter Exception form- My parents have attempted and are unable to obtain the
IRS Verification of Non-Filing Letter from the www.irs.gov website.
➢ Available on the CSUDH Financial Aid & Scholarships Office website at csudh.edu/financial-aid/forms/.
(Continue on next page)
Listed below are my parents sources of 2021 income earned from work, the amount of income from each
source, and all other sources of financial assistance received in 2021 to meet basic living expenses. I have
attached copies of all 2021 W-2 forms.
Source (Name of employer, person, agency, etc.)
Type (work, benefits,
Family assistance,
financial aid, etc.)
2021 Amount
Parent 1
2021 Amount
Parent 2
If more space is needed, attach a separate page with your (the student’s) name and student ID number at the top.
D.
If you or your parent(s) changed or corrected your original 2021 federal income tax return filed with the IRS, you
must submit the item below:
Signed copy of the 2021 Amended U.S. Individual Income Tax Return (1040X) with all schedules attached that
was filed with the IRS.
E.
CERTIFICATION AND SIGNATURE
Each person signing below certifies that all of the
information reported is complete and correct. The
student and one parent whose information was
reported on the FAFSA or CADAA must sign and date.
WARNING: Per the U.S. Department of Education and
the State of California, if you purposely give false or
misleading information you may be fined, be
sentenced to jail, or both.
Student’s Signature (Required) Date
Parent’s Printed Name Parent’s Signature (Required) Date