Student Verification Form printable pdf download

STUDENT

Worksheet A

PARENT

$________Earned income credit from IRS Form 1040-line 63; 1040A Line 41; 1040EZ-line 8;

$________

or Telefile-line L

$________Additional child tax credit from IRS Form 1040-line 65 or 1040A-line 42

$________

$________ Welfare benefits, including Temporary Assistance for Needy Families (TANF).

$________

Don’t include food stamps or subsidized housing.

$________Social Security benefits received, for all household members as reported in question

$________

84 (or 65 for your parents),that were not taxed (such as SSI)

$________ TOTAL

TOTAL $________

Worksheet B

$________ Payments to tax-deferred pension and savings plans (paid directly or withheld

$_________

from earnings), including, but not limited to, amounts reported on the W-2 Form in

Boxes 12a through 12d, codes D, E, F, G, H, and S.

$________ IRA deductions and payments to self-employed SEP, SIMPLE, and Keogh and

$________

other qualified plans from IRS Form 1040—total of lines 24 + 30 or

1040A—line 17

$________Child support received for all children. Don’t include foster care or adoption

$_________

payments.

$________Tax exempt interest income from IRS Form 1040—line 8b or 1040A—line 8b.

$________

$________ Foreign income exclusion from IRS Form 2555—line 43 or 2555EZ—line 18.

$________

$________ Untaxed portions of IRA distributions from IRS Form 1040—lines(15a minus 15b)

$________

or 1040A—lines (11a minus 11b). Exclude rollovers. If negative, enter a zero here.

$________ Untaxed portions of pensions from IRS Form1040—Lines (16a minus 16b) or 1040A $________

lines (12a minus 12b). Exclude rollovers. If negative, enter a zero here

$________ Credit for federal tax on special fuels from IRS Form 4136 line 10 nonfarmers only

$________

$________Housing, food, and other living allowances paid to members of the military, clergy

$________

and others (including cash payments and cash value of benefits)

$________ Veterans’ noneducation benefits such as Disability, Death Pension, or Dependency

$________

& Indemnity Compensation(DIC) and/or VA Educational Work-Study allowances

$________ Any other untaxed income or benefits not reported elsewhere on Worksheets A and B $_______

such as workers’ compensation, untaxed portions of railroad retirement benefits, Black

Lung Benefits, disability, etc.

Don’t Include student aid, Workforce Investment Act educational or benefits from flexible

Spending arrangements, e.g. cafeteria plans.

$_______ Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this

XXXXXX

form.

$________ TOTAL

TOTAL $_________

Worksheet C

$________Education credits (Hope and Lifetime Learning tax credits) from IRS Form

$_________

1040—line 47 or 1040A—line 31

$________Child Support paid because of divorce or separation or as a result of a legal

$_________

requirement. Don’t include support for children in your (or your parents’)

household, as reported in question 84 (or question 65 for your parents).

$________Taxable earnings from need-based employment programs, such as Federal

$_________

Work-Study and need-based employment portions of fellowships and

Assistantships.

$________Student grant and scholarship aid reported to the IRS in your (or your parents’)

$_________

adjusted gross income. Includes Americorps benefits (awards, living allowances,

and interest accrual payments), as well as grant scholarship portions of fellowships and

assistantships.

$________ TOTAL

TOTAL $_________

Student Verification Form

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