2010-2011 Verification Worksheet Template Page 2
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2C. Student’s Tax Forms and Income Information (all applicants)
Dependent
1. Check only one box below. Tax returns include the 2009 IRS Form 1040, 1040A, 1040EZ, a tax return from Puerto Rico or a foreign
income tax return. If you did not keep a copy of your tax return, request a copy from your tax preparer or request an Internal Revenue
Service form that lists tax account information.
Check here if you are attaching a signed copy of your tax return.
Check here if a signed tax return will be submitted to the school by ______________________(date).
Check here if you will not file and are not required to file a 2009 U.S. Income Tax Return.
2. Funds received for child support and other untaxed income. (See Question 45 of the Free Application for Federal Student Aid
(FAFSA).)
Sources of Untaxed Income
2009 Amount
Sources of Untaxed Income
2009 Amount
a. Child Support
$
d.
$
b. Workman’s Compensation
$
e.
$
c. Untaxed Pensions
$
f.
$
3. If you did not file and are not required to file a 2009 Federal income tax return, list below your employer(s) and any income received
in 2009 (use the W-2 form or other earnings statements if available).
Source
2009 Income
$
$
$
D. Parent(s)’ Tax Forms and Income Information
1. Check only one box below. Tax returns include the 2009 IRS Form 1040, 1040A, 1040EZ, a tax return from Puerto Rico or a foreign
income tax return. If your parent(s) did not keep a copy of their tax return, request a copy from their tax preparer or request an
Internal Revenue Service form that lists tax account information.
□
Check here if you are attaching a signed copy of your parents’ tax return(s).
□
Check here if a signed tax return(s) will be submitted to the school by ______________________(date).
□
Check here if your parent(s) will not file and are not required to file a 2009 U.S. Income Tax Return.
2. Funds received for child support and other untaxed income. (See Question 93 of the FAFSA.)
Sources of Untaxed Income
2009 Amount
Sources of Untaxed Income
2009 Amount
a. Child Support
$
d.
$
b. Workman’s Compensation
$
e.
$
c. Untaxed Pensions
$
f.
$
3. If your parent(s) did not file and are not required to file a 2009 Federal income tax return, list below your parent(s)’ employer(s) and
any income they received in 2009 (use the W-2 form or other earnings statements if available).
Sources
2009 Income
$
$
$
E. Sign this Worksheet
Each person signing this form certifies that all the information reported
WARNING: If you purposely give false or
on it is complete and correct. The student and at least one parent must sign.
misleading information on this worksheet, you
may be fined, be sentenced to jail, or both.
_______________________________________________________
Student
Date
_______________________________________________________
Parent
Date
Do not mail this worksheet to the Department of Education. Submit this worksheet to the College Board’s
Institutional Documentation Services (IDOC). Make sure that tax forms are signed.
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