Independent Student Civil Union Worksheet Page 2
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1
2Civil Union Partner
Student
D: Income, Earnings and Benefits Information
8A.
8B.
1.
1.
8. The following 2015 U.S. income
1. A completed 2015 IRS Form 1040A or 1040EZ
2.
2.
tax figures are from …
2. A completed 2015 IRS Form 1040
3.
3.
(Check only one box.)
3. An estimated 2015 IRS Form 1040A or 1040EZ
4.
4.
4. An estimated 2015 IRS Form 1040
5.
5.
5. A tax return will not be filed
9. 2015 total number of exemptions
(IRS Form 1040-line 6d or 1040A-line 6d. Form 1040EZ
9A.
9B.
filers – use the 1040EZ line 5 worksheet & enter 00, 01,or 02 to equal each $4,000 exemption for which
you qualify.)
10A.
10B.
10. 2015 adjusted gross income
$___________________.00
$____________________.00
(IRS Form 1040-line 37, 1040A-line 21, or 1040EZ-line 4.)
11. 2015 U.S. income tax paid
(IRS Form 1040-line 56 minus line 46, 1040A-line 28 minus line
11A.
11B.
$___________________.00
$____________________.00
36; or 1040EZ-line 10.)
12A.
12B.
$___________________.00
$____________________.00
12. 2015 income earned from work by
13A.
13B.
$___________________.00
$____________________.00
13. 2015 untaxed income
(FAFSA questions 45a-j)
14A.
14B.
$___________________.00
$____________________.00
14. 2015 untaxed Social Security benefits
15A.
15B.
$___________________.00
$________ ___________.00
15. 2015 taxable Social Security Benefits
16A.
16B.
$___________________.00
$________ ___________.00
16. 2015 Unemployment Compensation
17A.
17B.
$___________________.00
$________ ___________.00
17. 2015 Earned Income Credit
Civil Union Partner
Student
E: Asset Information
18A.
18B.
$___________________.00
$____________________.00
18. Cash, savings and checking accounts
19. Other real estate and investments
19A.
19B.
$___________________.00
$____________________.00
(Don’t include the home you live in)
20. Business/Investment farm*
20A.
20B.
$___________________.00
$____________________.00
* Do not include the value of a family farm that the student (and civil union partner)
live on and operate. Do not include the value of a small business that student (and
civil union partner) own and control that has 100 or fewer full-time or full-time equivalent
employees.
F: Other Information and Signatures
`Civil Union Partner/Other Household Member
Student
21. COLLEGE ATTENDANCE Effective
Fall 2016
Spring 2017
Name of College
22A.
22F.
Supplemental Security Income
Supplemental Security Income
22B.
22G.
City
SNAP
SNAP
22C.
22H.
Free or Reduced Price Lunch
Free or Reduced Price Lunch
22. In 2014 or 2015, did the student and/or civil union partner or
anyone in the household receive benefits from any of the
22D.
22I.
TANF
TANF
federal benefit programs listed?
(Mark all of the programs that apply.)
22E.
22J.
WIC
WIC
Please be advised that the New Jersey Higher
Education Student Assistance Authority has the right
to audit/verify this information to ensure your State
student aid eligibility was accurately determined.
Student’s Signature
By signing, I (we) certify that the information provided herein is
_____________________________
Date ___/___/ ____
true and accurate to the best of my (our) knowledge. I (we)
understand that this information will be used by the New Jersey
(Please print) ___________________________________________
Higher Education Student Assistance Authority (HESAA) to
determine eligibility for State student financial aid programs,
Student’s Civil Union Partner’s Signature
___________________ Date ___/___/ ____
such as the Tuition Aid Grant program. I (we) recognize that the
information provided herein will be transferred as required to
(Please print) ___________________________________________
institutions designated as authorized recipients on the Free
Application for Federal Student Aid or other notification of
change in college choice and I (we) specifically authorize
HESAA to release that information for those purposes.
Revised 04/04/2016
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