Aid For Part-Time Study (A.p.t.s.) Application (Page 2 of 4) in pdf

12. Were you eligible to be claimed or were you claimed as a dependent on your parents' New York State or federal tax

return for the previous year?

YES

If yes, YOU MUST REPORT PARENTS' INCOME below.

NO - If no, read and sign the affirmation on the bottom of this page and if married, your spouse must also

sign and enter Social Security number. If you have dependents of your own other than a spouse,

check this box.

If you answered "YES" to question 12, that is, you were claimed or were eligible to be claimed as a tax

dependent, you must report parental income in question 14. If your parents (stepparents, adoptive

parents) filed a tax return as married, you must report total income for both parents.

13.

EXCLUSION OF PARENTS' INCOME - If your parents are divorced, separated, never married or one of your parents

is deceased, report in question 14 the income of the parent with whom you lived most in the previous year or who

had custody or would have had custody if you were a minor.

TO EXCLUDE THE INCOME OF YOUR FATHER (Stepfather, adoptive father) OR MOTHER (stepmother, adoptive

mother) give the reason by checking the appropriate box. Enter the date of death or separation/divorce and enter

the amount of support received if separated/divorced. Only one parent's income can be excluded for

separation/divorce.

FATHER deceased

GIVE EARLIEST DATE

To exclude FATHER's Income

separated or divorced

Year

Month

MOTHER deceased

GIVE EARLIEST DATE

To exclude MOTHER's Income

separated or divorced

Year

Month

Support Amount - Enter the amount of support received for you from the parent

.00

whose income is to be excluded. If none, enter zero.

DOLLARS

Cents

Any separation must be by judicial decree or pursuant to an agreement of

(Note:

separation which is filed by a court of competent jurisdiction.)

ENTER PARENTS' EXEMPTIONS AND NET TAXABLE INCOME

14.

OFFICE USE ONLY

(NTI) IN THE BOXES PROVIDED.

.00

Father's Separate NTI

Mother's Separate NTI

OR Joint NTI with Mother

.00

Exemptions

Income

Exemptions

Income

.00

DOLLARS

Cents

DOLLARS

Cents

DOLLARS

Cents

ALL PERSONS WHOSE INCOMES ARE LISTED IN QUESTIONS 11 AND 14 must read and sign the affirmation.

15.

AFFIRMATION - I hereby certify that all the information provided by me upon this application is accurate and

complete. This information will be accepted for all purposes as the equivalent of an affidavit and, if it contains a false

statement, shall subject me to the same penalties for perjury as if I had been duly sworn. I authorize the school to

release to Higher Education Services Corporation (HESC) any information requested pertinent to this application. I

consent to the verification by HESC of any statement made herein and authorize the NYS Department of Taxation

and Finance to release to HESC certified copies of my personal income tax returns. I consent to the release by HESC

of such information as may be provided by law or regulation in the course of financial aid program administration.

Student's Signature

Date

Spouse's

SSN

Student's Spouse's Signature

Date

First 3 Letters of

Father's

SSN

Last Name

Father's Signature

Date

First 3 Letters of

Mother's

SSN

Last Name

Mother's Signature

Date

BRING OR MAIL THE COMPLETED APPLICATION TO YOUR SCHOOL'S FINANCIAL AID OFFICE.

H8073B (Rev. 03/2003)

Aid For Part-Time Study (A.p.t.s.) Application Page 2

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