Student/Spouse Verification of Information Not Transferred Through the IRS Data Retrieval Process

FA19C401

 

Student/Spouse
IRS Non-Transfer

New regulations from the Department of Education requires institutions to confirm or correct some information that was retrieved from the IRS.

Please complete the information below. If you are married, also include your spouse’s information. Please complete, sign, and return this form to the Financial Aid Office.

For 2017, have you (and your spouse, if applicable) completed an IRS income tax return? (Please check all that apply.)
Yes, I completed an IRS 1040.
Yes, I completed an IRS 1040A or 1040EZ.
Yes, I completed a foreign tax return.
(If you filed or will file a foreign tax return, a tax return with Puerto Rico, another U.S. territory (e.g., Guam, American Samoa, the U.S. Virgin Islands, Swain’s Island or the Northern Marianas Islands) or one of the Freely Associated States, use the information from that return to fill out this form. If you filed a foreign return, convert all monetary units to U.S. dollars, using the published exchange rate in effect for the date nearest to today’s date. To view the daily exchange rates, go to federalreserve.gov/releases/h10/current.)
I will file but have not yet completed my return.
I am not going to file
I filed a joint return with my spouse (if applicable).
My spouse (if applicable) filed a separate IRS tax return.
I am not married.
How much did you earn from working in 2017?
$
How much did your spouse (if applicable) earn from working in 2017
$
Earnings (wages, salaries, tips, etc.) may be on the W-2 forms or on the tax return: IRS Form 1040 – lines 7 + 12 + 18 + Box 14 (Code A) of IRS Schedule K-1 (Form 1065); 1040A – line 7; or 1040EZ – line 1.
If any individual earning item is negative, do not include that amount
WARNING:
According to the U.S. Department of Education, if you purposely give false or misleading information on form, you may be fined, sent to prison, or both.

Student’s 2017 Untaxed Income
(Enter the amount for spouse, if applicable)

Payments to tax-deferred pension and retirement 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. Do not include amounts reported in code DD (employer contributions toward employee health benefits).
$
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 any of your 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).
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 & Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances.
$
Other untaxed income not reported above, such as workers’ compensation, disability benefits, etc. Also, include the untaxed portions of health savings accounts from IRS Form 1040 – line 25.
Do not include extended foster care benefits, student financial aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security benefits, Supplemental Security Income, Workforce Innovation and Opportunity Act educational benefits, on-base 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. This includes money that you received from a parent or other person whose financial information is not reported on this form and that is not part of a legal child support agreement. (Money received, or paid on your behalf, also includes distributions to you (the student beneficiary) from a 529 plan that is owned by someone other than you or your parents (such as your grandparents, aunts, uncles, and non-custodial parents). Include these amounts here.
$

Student’s 2017 Additional Financial Information
(include the amounts for your spouse, if applicable)

Education credits (American Opportunity Tax Credit and Lifetime Learning Tax Credit) from IRS Form 1040 – line 50 or 1040A – line 33.
$
Child support paid because of divorce or separation or as a result of a legal requirement.
(Do not include support for 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.
$
Taxable college grant and scholarship aid reported to the IRS as 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.
Do not include untaxed combat pay.
$
Earnings from work under a cooperative education program offered by a college.
$

Certifications and Signatures

By providing your signature, you are certifying that all of the information on this form is complete and correct. You are also authorizing Johnston Community College to make corrections to your original and/or subsequent applications based on the documents you are now submitting.

WARNING:

If you purposely give false or misleading information, you may be fined, sent to prison, or both.
Student Signature
Date
Student ID #
By checking this box, I ratify the use of my typed name and Student ID number as an electronic representation of my signature.
©