2023-2024 Dependent Verification Worksheet

[DPVWEV]

Your 2023-24 Free Application for Federal Student Aid (FAFSA) was selected to be reviewed in a verification process. The purpose of this form is
to collect the full name, age and relationship of the household members you included in the household size for the 2023-24 academic year. If a
household member will be attending college at least half-time as a degree-seeking student between July 1, 2023 and June 30, 2024, include the
name of the college. The household size and number in college reported on this form will be compared to the household size and number in
college reported on your FAFSA. If there are differences, your FAFSA information may be corrected. Additional information may be required to
resolve potentially conflicting information.

Verification Instructions: https://www.mtsu.edu/financial-aid/docs/2324VerificationInstructions.pdf

A. Dependent Student's Information

Last Name First Name M.I. MTSU ID Number Date of Birth

* Eshak * Marina * M01587877 * 03-10-2005

Street Address (include apt. #) City State Zip Code

* 2308 Blue Heron Dr * Murfreesboro * TN 37128-1844

E-mail Address Home Phone Number Cell Phone Number

* me4v@mtmail.mtsu.edu 615-545-3186

Select school year: * Fall 2023, Spring 2024,Summer 2024

B. Student’s Number of Household Members: List the full name (First and Last Name), age and relationship of each person you included in your
household size on the FAFSA. If a member of the household (excluding parents of dependent students) will be attending college at least half-time as a degree-
seeking student between July 1, 2023 and June 30, 2024, include the name of the college to verify household members in college.

What is the current marital status of the biological parent reported on the FAFSA? * Married 

Enter information for Parent 1 and Parent 2:

Parent 1's Full Name: * Saad Loza Age: * 46 Relationship: * Father

Parent 2's Full Name: * Merfat Gadelseed Age: * 38 Relationship: * Mother

Do you have any siblings/step-siblings? * Yes 

Will your parent(s) provide more than 50% of their support between July 1, 2023 and June 30, 2024? * Yes 

Please enter their information below:

Full name: Age: Relationship: Do they attend college? N/A Do you want to add another?
* Saad Loza * 46 * Father * No  * No 
 2023-2024 Dependent Verification Worksheet

MTSU Student ID: * M01587877 Last Name: * Eshak First Name: * Marina

Do you have any other household members to include? * No 

Household Summary - For Processing Purposes Only

Full Name Age Relationship to Student College

* Marina Eshak * 17 Self Middle Tennessee State University

Saad Loza 46 Father N/A

Merfat Gadelseed 38 Mother N/A

Saad Loza 46 Father

C. Certification

Each person signing this worksheet certifies that all of the information reported on it is complete and correct. The student and one parent whose information was
reported on the FAFSA must sign and date. An email will be sent to the parent's email address indicated when the form was started.

By signing this worksheet you certify the following:

I understand that if I knowingly and willingly provide false or misleading information or documentation to obtain federal aid, MTSU is required {Per 34 CFR
668.16 (g)(1)} to report the suspected fraud to the Office of Inspector General of the Department of Education for investigation. Suspicion of fraud may
require me to repay federal and/or state aid already received or make me ineligible from receiving federal and/or state aid for the aid year.

...3237333737

01/25/2023, 9:05 AM
Signature Date

MT One Stop, 1301 E. Main St, SSAC 260, Murfreesboro, TN 37132, Phone 615-898-2111

Middle Tennessee State University, in its educational programs and activities involving students and employees, does not discriminate on the basis of race, color, national origin, sex, religion,
or age. Furthermore, the university does not discriminate against veterans or individuals with disabilities

Parent Signature Electronic Signature Pending