Independent Student Verification Worksheet Page 3
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4Georgia Tech ID
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Office of Scholarships and Financial Aid
Step II: Additional Income
Please report the annual amount(s) received and make sure the page is completed in its entirety. If the
answer(s) are $0 or not applicable, please list $0.
Additional Financial Information
Student
Spouse
Education Credits from IRS Form 1040, Line 50 or 1040A Line 33 (American
$
$
Opportunity and Lifetime Learning Credit)
Child Support Paid (Do not include support for children living in your
$
$
household)
Name of Child:_________________________________
Taxable Earnings from need based employment programs, such as Federal
$
$
Work Study and need based portion of Fellowships and Assistantships
Taxable student grants and scholarship aid reported to the IRS in your
adjusted gross income (AGI), as well as grant and scholarship portions of
$
$
fellowships and assistantships. (Includes AmeriCorps awards, interest accrual
payments, and living allowances)
Combat or special combat pay (only enter the amount that was taxable and
$
$
included in your adjusted gross income (AGI)). Combat pay is reported on the
W2 box 12, Code Q.
Earnings from work under a Cooperative Education Program offered by a
$
$
college and/or university
Untaxed Income
Student
Spouse
Payments to tax-deferred pension and savings plans (paid directly or withheld
$
$
from earnings), including, but not limited to, amounts reported in the W-2
Form in Boxes 12a-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 Form 1040-total of lines 28 + 32 or 1040A-line
17.
Child Support RECEIVED for all children. Do not include foster care
$
$
or adoption payments.
Tax exempt interest income from Form 1040, line 8b or 1040A, line 8b
$
$
Untaxed portions of IRA distributions from 1040- lines (15a minus 15b) or
$
$
1040A- lines (11a minus 11b). Exclude rollovers. If negative, enter “0”.
Untaxed portions of pensions from 1040- lines (16a minus 16b) or 1040A-
$
$
lines (12a minus 12b). Exclude rollovers. If negative, enter “0”.
Housing, food, and other living allowances paid to members of the military,
clergy, and others (including cash payments and cash value of benefits). Do
$
$
not include the value of on-base military housing or the value of a basic
military allowance for housing.
Veterans’ non-education benefits such as Disability, Death Pension, or
$
$
Dependency and Indemnity Compensation (DIC) and/or VA Educational
Work-Study allowances.
Other untaxed income not reported in items, such as workers’ compensation,
disability, untaxed portions of health savings accounts from IRS Form 1040 –
line 25, etc. Do not 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, 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.
225 North Ave. Atlanta, GA 30332-0460
Phone: 404.894.4160 Fax: 404.894.7412
**Faxes are received by a secure server**
Via Email: finaid@gatech.edu
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