Verification Worksheet Federal Student Aid Programs - 2015-2016 Page 4
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Additional Financial Information and Untaxed Income
Use the tables on the next page to report annual (not monthly) amounts as indicated on your 2014 TAX RETURN.
Tax returns include the 2014 IRS Form 1040, 1040A, 1040EZ, a tax return from Puerto Rico, or a foreign tax return.
If the amount is zero, write “0”, do not leave blank.
PARENT’S
2014 Additional Financial Information
STUDENT’S
$
a.
Education Credits (Hope and Lifetime Learning tax credits) from IRS Form
$
1040 –line 49 or 1040A – line 31
$
b.
Child support paid by the parent you live with because of divorce or separation or as a result
$
of legal requirement. You must supply a statement from the payer of the child support
indicating the annual amount of support and the names of the children for which the funds
are being paid. (The statement must be signed by both the payer and SJC student.)
$
c.
Taxable earnings from need-based employment programs, such as Federal Work-Study and
$
need-based employment portions of fellowships and assistantships
$
d.
Grant and scholarship aid reported to the IRS in your adjusted gross income. Includes
$
AmeriCorps benefits (awards, living allowances, and interest accrual payments), as well as
grant and scholarship portions of fellowships and assistantships.
$
e.
Combat pay or special combat pay. Only enter the amount that was taxable and included in
$
your adjusted gross income.
$
f.
Earnings from work under a cooperative education program offered by a college (do not
$
include earnings from any SJC work program).
PARENT’S
2014 Untaxed Income
STUDENT’S
$
a.
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 forms in Boxes 12a through 12d:
codes D, E, F, G, H, and S. (Must submit W-2)
$
b.
IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualified plans
$
from IRS Form 1040 – line 28 + line 32 or 1040A- line 17.
$
c.
Child support received for all children in your household.
$
(Don’t include foster care or adoption payments)
$
d.
Tax exempt interest income from IRS Form 1040 – line 8b or 1040A – line 8b
$
$
e.
Untaxed portions of IRA distributions from IRS Form 1040 –lines 15a minus 15b or 1040A –
$
lines 11a minus 11b. Exclude rollovers. (Must submit 1099R)
$
f.
Untaxed portions of pensions from IRS Form 1040 lines 16a minus 16b or 1040A lines 12a
$
minus 12b. Exclude rollovers. If negative, enter “0”. (Must submit 1099R).
$
g.
Housing, food, and other living allowances paid to members of the military, clergy, and
$
others (including cash payments and cash value of benefits).
$
h.
Veterans’ non-education benefits such as Disability Death Pension or Dependency &
$
Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.
$
i.
Other untaxed income not reported elsewhere on this form, such as workers’ compensation,
$
disability, etc. Also include the first-time homebuyers tax credit from IRS form 1040, line 67.
Do not include student aid, earned income credit, child tax credit, welfare payments,
untaxed Social Security benefits, Workforce Investment Act educational benefits, combat
pay, (if you are not a tax filer), benefits from flexible spending arrangements (e.g. cafeteria
plans), foreign income exclusion or credit for federal tax on special fuels.
$
j.
Money received or paid on your behalf (e.g. bills), not reported elsewhere on this form.
$
Were you (your household) supported in 2014 by any of the following income?
Yes
No
Untaxed student financial aid, welfare, any kind of Social Security benefits, Workforce Investment Act educational
benefits, combat pay (if you are not a tax filer), benefits from flexible spending arrangements (e.g. cafeteria plans),
foreign income exclusion, or credit for federal tax on special fuels (Do not include income already reported somewhere
else on this form).
Sign this Worksheet
Each person signing this form certifies that all the information reported on it is complete and correct. The student
and at least one parent must sign and date.
WARNING: If you purposely give
Student
Date
false or misleading information on
this worksheet, you may be fined, be
sentenced to jail, or both.
Parent
Date
3
SJC ID/Student’s Name: _________________________________________________________________
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