Minnesota - Wisconsin Application Form For Reciprocity Benefits Page 4
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415. Did you receive reciprocity benefits in any prior years?
( ) NO ( ) YES
If YES, name of institution __________________________________________ from ___/___/___ to ___/___/___
16. Were you or will you be claimed as a dependent?
a. On parents or guardians 2014 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
b. On parents or guardians 2015 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
17. Did you or will you claim yourself?
a.
On your 2014 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
b.
On your 2015 Federal/State Income Tax?
NO ( ) YES ( )
If yes, what state? _____________________
18. What was your status in 2014?
a. Employed?
NO ( ) YES ( ) If yes, dates employed ______________________________
NO ( ) YES ( ) If yes, institution ___________________________________
b. Full-time Student?
c. Part-time Student?
NO ( ) YES ( ) If yes, institution ___________________________________
d. Graduate Assistant?
NO ( ) YES ( ) If yes, institution ___________________________________
e. Other?
NO ( ) YES ( ) If yes, explain _____________________________________
THIS APPLICATION MUST BE COMPLETED IN FULL AND SIGNED BY THE APPLICANT. IF THE
APPLICATION IS NOT COMPLETE, IT WILL BE RETURNED TO THE APPLICANT FOR COMPLETION AND
THE PROCEES WILL BE DELAYED. THE APPLICATION MUST BE SUBMITTED TO THE APPROPRIATE
AGENCY BY THE DEADLINE IN ORDER TO BE CONSIDERED. See instruction sheet for information
regarding deadlines.
CERTIFICATION
I HAVE READ THE INSTRUCTIONS ON THE ATTACHMENT TO THIS APPLICATION
CONCERNING MY RESPONSIBILITIES. I declare under penalty of criminal laws of the State of
Wisconsin/Minnesota that this application has been examined by me and to the best of my knowledge
and belief is true, correct and complete.
Applicant’s Signature:
Date:
Email Address (optional)
Telephone Number:
(include area code) (
) ________ - _____________
Minnesota residents enrolling in Wisconsin institutions
Wisconsin residents enrolling in Minnesota institutions
return application to:
return application to:
Minnesota Office of Higher Education
Wisconsin Higher Educational Aids Board
Reciprocity Program
Reciprocity Program
1450 Energy Park Drive, Suite 350
PO Box 7885
St. Paul, MN 55108-5227
Madison, WI 53707-7885
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