Fillable 2010-2011 Independent Student Verification Form (Page 2 of 2) in pdf

Students and spouse (if married) must fill out all sections below. Report yearly amounts for 2009, not monthly amounts. If the

answer is zero, please write 0.

2009 ADDITIONAL FINANCIAL INFORMATION

Education credits (American Opportunity, Hope & Lifetime Learning Credits) from IRS Form 1040-line 49 or

Form 1040A-line 31.

Child support PAID because of divorce or separation. Do not include support for children living in your

household. Names and ages of children you paid support for:

Name ___________________ Age _____

Name _____________________ Age ______

Name ___________________ Age _____

Name _____________________ Age ______

Taxable earnings from need-based employment programs such as Federal or State Work-Study and need based

employment portions of fellowships and assistantships.

Student grant, scholarship, fellowship, and assistantship aid including AmeriCorps awards that you reported to

the IRS in your adjusted gross income.

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).

Earnings from work under a cooperative education program offered by a college.

2009 UNTAXED INCOME

Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including

amounts reported on the W-2 Form in Boxes 12a through 12d, codes D, E, F, G, H, and S.

IRA deductions and payments to self employed SEP, SIMPLE, and Keogh and other qualified plans from IRS

Form 1040-line 28 + 32 or Form 1040A-line 17.

Child support received for any of your children. Don’t include foster care or adoption payments.

Tax exempt interest income from IRS Form 1040-line 8b or Form 1040A-line 8b.

Untaxed portions of IRA distributions from IRS Form 1040-lines (15a minus 15b) or Form 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 Form 1040A-lines (12a minus

12b). Exclude rollovers. If negative, enter a zero here.

Housing, food, and other living allowances paid to members of the military, 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.

Veterans noneducation benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation

(DIC) and/or VA Educational Work-Study allowances.

Any other untaxed income and benefits not reported elsewhere, such as unemployment benefits, workers’

compensation, disability, etc. Don’t include student aid, earned income or additional child tax credit, welfare

payments, untaxed Social Security benefits, Workforce Investment Act educational benefits, combat pay,

benefits from flexible spending arrangements (e.g. cafeteria plans), foreign income exclusion or credit for

federal tax on special fuels.

Money received, or paid on your behalf (e.g., bills), not reported elsewhere on this form.

SIGN THIS WORKSHEET

BY SIGNING THIS WORKSHEET, I (WE) CERTIFY THAT ALL OF THE INFORMATION REPORTED ON THIS

WORKSHEET IS COMPLETE AND CORRECT.

WARNING: IF YOU PURPOSELY GIVE FALSE OR MISLEADING INFORMATION ON THIS WORKSHEET, YOU

MAY BE FINED, SENTENCED TO JAIL, OR BOTH.

STUDENT’S SIGNATURE

DATE

SPOUSE’S SIGNATURE (optional)

DATE

VER. 041410

2010-2011 Independent Student Verification Form Page 2

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