Recent Separation/divorce Form (Dependent Student)
ADVERTISEMENT
1
2
314B35 – 12/13
TGSD 14
State Grant and Special Programs
Phone: 1-800-692-7392
Fax: 717-720-3786
P.O. Box 8157 Harrisburg, PA 17105-8157
RECENT SEPARATION/DIVORCE FORM
(DEPENDENT STUDENT)
(NOTE: Deadline for returning this form and requested documentation to PHEAA is April 1, 2015.)
Student’s Account Number
_______________________________________________
Print Student’s Name
OR
Student’s Social Security Number
2014-15
It is the policy of this Agency to consider an application based on the income of the parent with whom the student
resides the most when the parents have been separated for at least two full months. In order for PHEAA to
properly determine your 2014-15 Pennsylvania State Grant eligibility, complete the following, have the appropriate
person(s) sign, and return this form and the requested documentation to PHEAA, P.O. Box 8157, Harrisburg, PA
17105-8157 within 30 days, once the two-month condition is met. Do not leave any questions blank. IF NONE,
ENTER ZEROS. No data will be accepted after April 1, 2015.
The date of your parents’ (or parent and stepparent’s) separation. __________________ (month/day/year)
1.
The date of your parents’ (or parent and stepparent’s) divorce. _____________________ (month/day/year)
2.
If your parents (or parent and stepparent) separated or divorced prior to the filing of your Pennsylvania
State Grant application, indicate the name, physical address (no P.O. Boxes), and phone number of the
parent you resided with the most during the 12 months immediately preceding the filing date of your
application. If your parents separated or divorced after your application was filed, indicate the name and
physical address of the parent with whom you have resided the most since your parents’ separation or
divorce.
_____________________________________________________________________________________
Provide a complete copy of your parent’s 2013 U.S. Income Tax Return including all supporting forms,
3.
schedules and W-2 Forms, if such has not previously been submitted. If your parent(s) have an interest in
a corporation and/or partnership you also need to submit copies of the most recent U.S. Partnership and/or
Corporation Tax Return(s), including the completed balance sheet(s) and K-1 schedule(s).
Enter the above parent’s portion of the ADJUSTED GROSS INCOME shown on the 2013 U.S. Income Tax
4.
Return (Form 1040 – line 37; Form 1040A – line 21; Form 1040EZ – line 4; or Form 1040X – line 1).
$_______________________
5.
2013 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. $_______________________
6.
2013 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. $_______________________
7.
Child support received for all children in 2013.
Do not include foster or adoption payments.
$_________________
PHEAA conducts its student loan servicing operations commercially as American
Education Services and for federally-owned loans as FedLoan Servicing.
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal