Confidential Family Financial Statement Page 3
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1
2
3
4Income, Earnings, and Benefits
Student Tax Form:
Completed 1040A or 1040EZ/Completed 1040/Will Not File/ Will File
Parent(s) Tax Form:
Completed 1040A or 1040EZ/Completed 1040/Will Not File/ Will File
Round figures to the nearest dollar.
Student (& Spouse)
Parent(s)
1.
Total # of exemptions (Form 1040, 1040A, or 1040EZ)
2.
Adjusted Gross Income (AGI from 1040, 1040A, or 1040EZ)
3.
U.S. income tax paid (1040, 1040A, or 1040EZ)
4.
Income earned from work
5.
Income earned from work (spouse)
Untaxed Income and Benefits
6. Education Credits
7. Earned Income Tax Credit
8. Additional Child Tax Credit
9. Combat Pay
10. Child Support paid for all children
11. Child support received for all children
12. Untaxed Pension Contributions
13. Untaxed Pension Distributions
14. IRA Deductions and Contributions
15. Untaxed IRA Distributions
16. Tax Exempt Interest Income
17. Military/Clergy Allowances
18. Veterans Non-Education Benefits
19. Workman’s Compensation
20. Medical/Dental Expenses
21. All other untaxed income and benefits
Asset Information
Student (& Spouse)
Parent(s)
1. Do you own a business or farm?
Yes/No
Yes/No
2. Net Worth of Business/Farm
$
$
3. Cash, savings and checking accounts
(DO NOT include IRAs)
$
$
4. Other real estate value (DO NOT
Include primary residence)
$
$
5. Other real estate debt (DO NOT
Include primary residence)
$
$
6. Investment value (Exclude 403b.
401k, IRA, PSP, etc.)
$
$
7. 529 Plan for applicant student
$
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