Frostburg State University Office Of Student Financial Aid Page 2
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2SECTION C: STUDENT’S 2010 TAX INFORMATION
Please list the total wages earned in 2010 (from January 1, 2010 through December 31, 2010)
Employer
Wages earned in 2010
Student:
$
Check and attach SIGNED 2010 Federal tax return (1040). (State tax forms or W2’s are not acceptable)
You must submit a copy of your tax return. If you do not have a copy, you can request one from the tax preparer or a
copy from the Internal Revenue Service at
(800) 829-1040.
•
Acceptable Federal Tax Returns: 1040EZ, 1040A, or Form 1722 or RTFTP from the IRS - we are not able to accept
Form 8453 – U.S. Individual Income Tax Declaration Form.
•
If an amended tax return was filed, you must submit copies of both the amended tax return AND the original.
•
Signatures are required on all tax forms.
Check here if you will not file and are not required to file a 2010 Federal Income Tax Return.
SECTION D: PARENTS’ & STUDENT’S 2010 UNTAXED INCOME - Do not leave any question blank.
Did you receive any untaxed income in 2010?
PARENT(S)
STUDENT
Yes No
Amount
Yes No
Amount
Sources of UNTAXED income
• Social Security benefits:
$________
$________
• SSI benefits:
$________
$________
If yes, you must attach form 1099 or a printout from the Social Security Administration (SSA) listing the TOTAL amount of
benefits received for the year of 2010 by ALL family members. You may contact the Social Security Administration at
(800) 772-1213 or online at
for documentation.
• Workman’s Compensation:
$________
$________
• TANF (AFDC/ADC)? If yes, list total for year?
$________
$________
• Child support received?
$________
*****
*List total received for the year for All children.
• Payments to a tax-deferred pension plan
$________
$________
(Such as a 401k or 403b) in 2010? (Box 12 on W2)
• Any other untaxed income in 2010?
$________
$________
*Please specify source:_________________________
• Cash support from relative or friend?
*****
$________
SECTION E: INCOME EXCLUSIONS
Yes No Amount
Yes
No
Amount
• Did you PAY child support in 2010?
$________
$________
* Please list total amount paid in the year.
* Names and ages of children for whom you paid: ___________________________________________
• Did you report any of your student financial aid as
part of your adjusted gross income in 2010?
$________
$________
• Did you receive benefits under the National and
Community Service Trust Act (AmeriCorps)?
$________
$________
SECTION F: Statement of Certification
:
I certify that the information given on this form is true and complete.
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or
both
___________________________________________
_____________________________________________
Student Signature
Date
Parent Signature
Date
PLEASE RETURN TO: Frostburg State University · Office of Student Financial Aid · 101 Braddock Road,
Frostburg, MD 21532 · Phone: 301-687-4301 · Fax: 301-687-7074
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