Verification Worksheet Page 2
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34.
Funds Paid for Child Support
If you paid child support in 2011 because of a divorce or separation or as a result of a legal requirement, please complete the following information:
Name of Person Who Paid Child
Name of Person to Whom Child
Name of Child(ren) for Whom
Amount of Child Support Paid
Support
Support was Paid
Support Was Paid
in 2011
Marty Jones(example)
Chris Smith
Terry Jones
$6,000.00
5.
Food Stamps
Check here if you received food stamps during 2011. If you or anyone in your household received Food Stamps, you must submit proof that
you received these benefits. Acceptable documentation includes receipts indicating the use of benefits or a copy of a benefit card with a year
and date of authentication.
Student
2011 Additional Financial Information
Parent(s)
$
a. Education credits (Hope and Lifetime Learning tax credits) from IRS Form 1040 line 49 or 1040A line 31.
$
b. Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based
$
$
employment portions of fellowships and assistantships.
c. Grant and scholarship aid reported to the IRS in the adjusted gross income (AGI). Includes AmeriCorps
$
benefits (awards, living allowances, and interest accrual payments), as well as grant or scholarship portions of
$
fellowships and assistantships.
d. Combat pay or special combat pay. Only enter the amount that was taxable and included in the adjusted
$
$
gross income. Do not enter untaxed combat pay reported on the W-2 (Box 12 Code Q).
e. Earnings from work under a cooperative education program offered by a college. This is a program
$
that the college may offer when you are able to receive income AND receiving college credit for a class. This
$
is not work study. OJC does not offer this.
$
TOTAL
$
Student
2011 Untaxed Income
Parent(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.
b. IRA deductions and payments to self-employed SEP, SIMPLE, and Keogh and other qualified plans form
$
$
IRS Form 1040—total of lines 28 + 32 or 1040A—line 17.
c. Child support you received for all children. 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
$
$
(11 a minus 11 b). Exclude rollovers. If negative, enter a zero here.
f. 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.
g. Housing, food, and other living allowances paid to members of the military (BAS), clergy, and
$
others (including cash payments and cash value of benefits). Don’t include the value of on-base military
$
housing or the value of a basic military allowance for housing.
h. Veterans’ non-education (ex. Chapter 30) benefits such as Disability, Death Pension, or Dependency &
$
$
Indemnity Compensation (DIC), and/or VA Educational Work-Study allowances.
i. . Other untaxed income not reported, such as workers’ compensation, disability, etc. Don’t include
student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social security
$
benefits, Supplemental Security Income, Workforce Investment Act educational benefits, on-base military
$
housing or a military housing allowance, 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.
$
$
$
TOTAL
$
**By signing this worksheet, I certify that all the information reported on both sides of this form is complete and correct. **
Student Signature
Date
Parent Signature (only one parent’s signature required)
Date
WARNING: if you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
1802 Colorado Ave, La Junta, CO 81050
(719) 384-6834 office
(719) 384-6933 fax
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