Federal Benefits/ Dislocated Worker Verification Form


You have reported on your 2014-15 FAFSA that you and/or a family member in your household is receiving at least one type of federal benefit and/or you or your spouse (if married) or your parent (if dependent) is a dislocated worker. Please check the appropriate spaces and/or boxes which indicate the benefit received in your household. Also, you will have to attach the required supporting documentation.

  Student Information






  Federal Benefits Verification

Please state if you are participating in the Federal Benefit program by selecting YES/NO to the following questions.

Please state if yourself, your spouse (If married), your parent (If dependent) are not receiving any federal benefits. Also you authorize

UNO financial Aid office to make the necessary corrections on your FAFSA.






Free or Reduced Lunch. You will need to submit a letter on school letter head indicating that your child is participating in this program.



Supplemental Nutrition Assistance Program (SNAP).--formerly known as Food Stamps: You will need to submit a "Certification 

Notification" or a benefit letter.



Supplemental Security Income (SSI). You will need to submit a "Proof of Income Letter" from the Social Security Administration (SSA), 

1-800-772-1213.



Special Supplemental Nutrition Program for Women, Infants, and Children (WIC). You will need to submit a copy of the WIC ID card.



Temporary Assistance for Needy Families (TANF). You will need to submit a "Certification Notification" or a letter from the Adult & 

Family Services Office.



  Dislocated Worker Verification

Please state if yourself, and/or your spouse(if married), or your parent(if dependent) is not a Dislocated Worker or Displaced 

Homemaker. Also you authorize UNO Financial Aid Office to make the necessary corrections on your FAFSA.






Please state if yourself, and/or your spouse(if married), or your parent(if dependent) is a Dislocated Worker. You will need to 

submit a copy of the notice of Termination or layoff, unemployment benefits, and/or quarterly estimated tax for self-employed.






Please state if yourself and/or your spouse(if married) or your parent(if dependent) is a displaced homemaker. You will need 

to submit copies of court documents, a divorce decree, a separation agreement, and/or tax returns that list you and your spouse and

reflect your financial dependence on this other family member.






  Signatures




If Dependent



If Married


Submit