Verification Worksheet Page 2
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1
2Parent(s)
Student/Spouse
WORKSHEET A
————————————
———————————
$
Earned income credit from IRS Form 1040-line 66a; 1040A-line 41a; 1040EZ-line 8a
$ XXXXXXX
$
Additional child tax credit from IRS Form 1040-line 68 or 1040A-line 41
$ XXXXXXX
$
Welfare benefits, including Temporary Assistance for Needy Families (TANF). Don’t include
$ XXXXXXX
Food Stamps or subsidized housing.
$
Social Security benefits received, for all household members as reported in question 90 (or 66
$ XXXXXXX
for your parents), that were not taxed (such as SSI)
$
TOTAL
TOTAL
$ XXXXXXX
(amount entered on line 40 of FAFSA)
(amount entered on line 84 of FAFSA)
Parent(s)
Student/Spou
WORKSHEET B
————————————
———————————
se
Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings),
$
$ XXXXXXX
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, and Keogh and other qualified
$ XXXXXXX
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.
$ XXXXXXX
Tax exempt interest income from IRS Form 1040-line 8b or 1040A-line 8b
$
$ XXXXXXX
A.
Foreign income exclusion from IRS Form 2555-line 45 or 2555EZ-line 18
$
$ XXXXXXX
$
Untaxed portions of IRS distributions from IRS Form 1040-lines (15a minus 15b) or 1040A-
$ XXXXXXX
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 1040A-lines (12a
$ XXXXXXX
minus 12b). Exclude rollovers. If negative, enter a zero here.
$
Credit for federal tax on special fuels from IRS Form 4136-line 20-nonfarmers only
$ XXXXXXX
$
Housing, food, and other living allowances paid to members of the military, clergy, and others
$ XXXXXXX
(including cash payments and cash value of benefits)
$
Veterans’ noneducation benefits such as Disability, Death Pension, or Dependency &
$ XXXXXXX
Indemnity Compensations (DIC) and/or VA Educational Work-Study allowances
$
Any other untaxed income or benefits not reported elsewhere on Worksheets A and B, such as
$ XXXXXXX
worker’s compensation, untaxed portions of railroad retirement benefits, Black Lung Benefits,
disability, etc. Tax filers only: report combat pay not included in AGI (FAFSA questions 35
and 79). 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
$ XXXXXXXX
$
TOTAL
TOTAL
$ XXXXXXX
(
(
amount entered on line 41 of FAFSA)
amount entered on line 85 of FAFSA)
Student/Spouse
Parent(s)
WORKSHEET C
————————————
———————————
$
Education credits (Hope and Lifetime Learning tax credits) from IRS Form 1040-line 50 or
$ XXXXXXX
1040A-line 31
$
Child support paid because of divorce or separation or as a result of a legal requirement. Don’t
$ XXXXXXX
include support for children in your (or your parents’) household, as reported in question 90
(or question 66 for your parents).
Taxable earning from need-based employment programs, such as Federal Work-Study and
$
$ XXXXXXX
need-based employment portions of fellowships and assistantships.
Student grant and scholarship aid reported to the IRS in your (or your parents’) adjusted gross
$
$ XXXXXXX
income. Includes AmeriCorps benefits (awards, living allowances, and interest accrual
payments), as well as grant or scholarship portions of fellowships and assistantships.
$
TOTAL
TOTAL
$ XXXXXXX
(
amount entered on line 42 of FAFSA)
(amount entered on line 86 of FAFSA)
I CERTIFY THAT ALL THE INFORMATION REPORTED ABOVE IS TRUE AND COMPLETE.
__________________________________________________ (STUDENT)
___________________ (DATE)
E)
__________________________________________________ (SPOUSE)
___________________ (DAT
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