Irs Form 2009 1040 Es by pel19120


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									                                                                              Student Banner ID_______________________

                             2010-2011 Dependent Verification Form

Your application has been selected for verification; therefore, you and your parent(s) must provide
the following information before any financial aid is awarded. You and at least one parent must sign
this form on the reverse side.

Forward the completed form, along with a signed copy of your and your parent(s) 2009 Federal Income Tax
Returns to the Financial Aid Office at Bridgewater State College, Tillinghast Hall, Bridgewater, MA

Student Name______________________________________________Social Security # XXX – XX - ________

Permanent Address________________________________________________________________________________


Permanent Phone (___)__________________                  Email Address ______________________________________

Parent’s marital status:         Single____      Married____       Divorced____       Separated____        Widowed____

                                            Household Information
Fill in the information about the people whom your parent(s) will support* between July 1, 2010 and June 30,
2011. Include your parent(s) and yourself. Include your parents’ other children if they get more than half
their support from your parents, or if they would be required to provide parental information when applying
for Title IV Federal Student Aid in 2010-2011. Include other people only if they now live with and get more
than half their support from your parent(s) and will continue to get this support between July 1, 2010 and
June 30, 2011.

Full Name                              Age     Relationship to Student        Name of College Attending 2010-11**
                                               Self                           Bridgewater State College

*Support includes money, gifts, loans, housing, food, clothes, car, medical and dental care, payment of college costs, etc.
**Must be accepted in degree program and attending college at least half-time in 2010-2011 (6 credits or more per

                                                  Federal Tax Return Information
            Student                                    Tax Status Statement                                         Parent(s)
                                                 Check applicable box(es)
                       I have filed a 2009 federal income tax return. Check and attach 2009 Federal
                       Income Tax Return. Include all W-2 forms and all schedules.
                       I (we) have filed for an extension from the IRS. Attach copy of IRS Form 4868.
                       I (we) did not file and am not required to file a 2009 tax return. Attach all
                       W-2 Forms.

        Income received from the following sources (Please check appropriate boxes below).
          Student                                                                                                      Parent(s)
                Welfare benefits including Temporary Assistance for Needy Families (TANF)
                Social Security Benefits that were not taxed
                Food Stamps or Subsidized Housing

Student                                       Untaxed Income Received in 2009                                                           Parent(s)
                Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), including
    $           amounts reported on 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 IRS
    $           Form 1040 – line 28 + line 32 or 1040A – line 17                                                                             $
    $           Child support received for all children. Do not include foster care or adoption payments.                                    $
    $           Tax exempt interest income from IRS Form 1040 – line 8b or 1040A line 8b                                                     $
                Untaxed portions of IRA distributions from IRS Form 1040 – lines (15a minus 15b) or 1040A – 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 minus
                12b). Exclude rollovers. If negative, enter a zero here.                                                                     $
                Housing, food, and other living allowances paid to members of the military, clergy, and others (including
    $           cash payments and cash value of benefits)                                                                                    $
                Veterans non-education 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, such as worker’s compensation, disability, etc. Don’t
                include student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social
                Security benefits, Workforce Investment Act educational benefits, 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.                                      XXXXXX

Student                                       2009 Additional Financial Information                                                     Parent(s)
$             Education credits (Hope and Lifetime Learning Tax credits) from IRS From 1040—line 49 or 1040A—line 31.                    $
              Child Support paid because of divorce or separation or as a result of a legal requirement. Don’t include support for
$             children in your household, as reported on FAFSA.                                                                          $
              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. Includes AmeriCorps benefits
              (awards, living allowances and interest accrual payments), as well as grant and scholarship portions of fellowships and
$             assistantships.                                                                                                            $
              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 in Box 12, Code Q.                                                                       $
$             Earnings from work under a cooperative education program offered by a college.


By my signature, I certify that all information submitted with and written on this application is complete, accurate, and
that corrections may be made based on data provided.
                                                                             WARNING: If you purposely give
______________________________________________                               false or misleading information on
Student Signature
                                                                             this worksheet, you may be fined,
_________________________________________________________  ________________  be sentenced to jail, or both.
Parent Signature (at least one parent must sign)                Date

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