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					                        Suffolk University Office of Student Financial Services
                                41 Temple Street Boston, MA 02114
                                  617-573-8470 617-720-3579 (fax)

                               2010-2011 Income Exclusion Worksheet

    Student’s Name ______________________Social Security Number _______________

    According to your FAFSA for the 2010-2011 academic year, you and/or your parents
    reported an income exclusion for the 2009 calendar year. In order to verify this exclusion,
    please complete, sign and return this form.

Student/Spouse                               Report Annual Amounts                                                     Parent(s)

             Education credits (Hope and Lifetime Learning tax credits) from IRS form 1040 line 49 or
             1040A line 31.

             Child support paid because of divorce or separation or as a result of a legal requirement.
             Indicate total amount of child support paid in 2009. Do not report child support received.

             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 (or your parents’) adjusted gross income.
             (Includes AmeriCorps benefits (awards, living allowances and interest accrual payments))

             Combat pay or special combat pay. Only enter the amount that was taxable and included in your
             adjusted gross income. Combat pay is reported on the W-2 form in Box12, code Q.

             Earnings from work under a Cooperative Education Program offered by a college.

$                                                         Total                                                         $

    Student’s Signature __________________________

    Parent’s Signature ___________________________
    (Parent must sign if child is a dependent student.)

    Date __________

    2010-11 income exclusion