Domestic Partnership Status Form For Parents - Office Of Financial Aid Page 3
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2
3Worksheet A - Report Annual Amounts
Earned income credit from IRS Form 1040 – line 64a; 1040A – line 38a; 1040EZ – line 8a.
$
Additional child tax credit from IRS Form 1040 – line 68 or 1040A – line 41.
$
Welfare benefits, including Temporary Assistance for Needy Families (TANF). Don’t include food stamps,
subsidized housing or WIC.
$
Social Security benefits received, for all household members not already reported on the FAFSA, that were not
taxed, including SSI.
$
TOTAL
$
Worksheet B - Report Annual Amounts
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, H and S
$
IRA deductions and payments to self-employed SEP, SIMPLE, KEOGH and other qualified plans from IRS
Form 1040 – total of lines 28 + 32 or 1040A – line 17
$
Child support 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 45 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 zero here.
$
Credit for federal tax on special fuels from IRS Form 4136 – line 17 (non-farmers only)
$
Housing, food and other living allowances paid to members of the military, clergy and others (including cash
payments and cash value of benefits).
$
Veteran’s noneducation benefits such as Disability, Death Pension, or Dependency & Indemnity Compensation
(DIC) and/or VA Educational Work-Study allowances.
$
Any other untaxed income or benefits not reported elsewhere on Worksheets A and B, such as worker’s
compensation, untaxed portions of railroad retirement benefits, Black Lung Benefits, disability, etc. Tax filers
only: report combat pay not included in AGI.
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
Worksheet C - Report Annual Amounts
Education credits (Hope and Lifetime Learning tax credits) from IRS Form 1040 – line 49 or 1040A – line 31
$
Child support you paid because of divorce or separation or as a result of a legal requirement. Don’t include
support for your children in your household.
$
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 adjusted gross income. Include AmeriCorps
benefits (awards, living allowance and interest accrual payments), as well as grant or scholarship portions of
fellowships and assistantships.
$
TOTAL
$
Parent Signature ____________________________________________
Date __________________________
Partner Signature ____________________________________________
Date __________________________
Student Signature ____________________________________________
Date __________________________
2/15/2012
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