2006-2007 Verification Worksheet Template Page 2
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2C. SUPPLEMENTAL INFORMATION
Student/Spouse
Worksheet A
Parent(s)
Earned income credit from IRS Form 1040 - line 66a; 1040A - line 41a; 1040EZ - line 8a; or TeleFile -
line L
$
$
Additional child tax credit from IRS Form 1040 - line 68 or 1040 A - 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). Report benefits paid to parents in the Parents column, and
benefits paid directly to student (or spouse) in the Student/Spouse column.
$
$
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,G and S. $
IRA deductions and payments to self-employed SEP, SIMPLE and Keogh and other qualified plans from
IRS Form 1040 - total of lines 28+32 or 1040A - line 17
$
$
Child support you 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 Form 1040 - 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 15 (non-farmers only)
$
$
Housing, food and other living allowances paid to member of the military, clergy and others (including
$
cash payments and cash value of benefits).
$
Veterans' noneducation benefits such as Disability, Death Pension, or Dependency and Indemnity
Compensation (DIC), and/or VA Education 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. Tax
filers only: report combat pay not included in AGI (FAFSA questions 35 and 73. Don't include student aid,
Workforce Investment Act educational benefits, 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 form
$
Total $
Total $
Worksheet C
Education credits (Hope and Lifetime Learning tax credits) from IRS Form 1040 - line 50 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
or scholarship portions of fellowships and assistantships.
$
$
Total $
Total$
By Signing this worksheet, I (we) certify that all information reported is complete and correct. You and one parent (if dependent)
must sign this form. If you are married, your spouse's signature is optional. Warning: If you purposely give false or
misleading information on this worksheet, you may be fined, sentenced to jail, or both.
Return this form with all documents attached to:
Central State University
Student Signature Date
Office of Student Financial Aid
PO Box 1004, 1400 Brush Row Rd.
Wilberforce, OH 45384
Parent Signature
Date
Do not leave any section blank.
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