2018-2019
Parent Tax Return Separation
Office of Student Financial Aid
1021 Dulaney Valley Road
Baltimore, Maryland 21204-2794
P: 410-337-6141
F: 410-337-6504
E: finaid@goucher.edu
The parent should submit this form if it is necessary to divide out the financial information from a jointly-filed return.
Additional clarifications or documents may be required after reviewing the information provided.
________________________________ _____________________ _____________________
Student Last Name Student First Name Goucher ID Number
Parent 1 Name: ________________________________ Parent 2 Name: ________________________________
Tax year for which this form is being submitted (2015, 2016, or 2017): __________________
Line item on federal tax return
Total, as indicated on
the federal tax return
Parent 1
Attributable Amount
Parent 2
Attributable Amount
Wages, salaries, and tips (1040 or
1040A line 7) {W2/1099 forms for both
parents will also be required}
Total income (1040 line 22, 1040A line
15)
Tax-exempt interest (1040 or 1040A
line 8b)
*Untaxed IRA distributions (1040 line
15a minus 15b, 1040A line 11a minus
11b; indicate $0 for negatives)
*Untaxed pensions and annuities (1040
line 16a minus 16b, 1040A line 12a
minus 12b; indicate $0 for negatives)
Business income or loss (1040 line 12)
Total adjustments (1040 line 36, 1040A
line 20)
IRA/Keogh deductions (1040 line 28
plus line 32, 1040A line 17)
* For rollovers, please indicate the amounts as showing on the actual federal tax return, attribute them appropriately,
and then attach and submit separate documentation that shows it is a rollover.
By signing this form, I certify all information reported on this form & within the enclosed documentation is complete & correct.
_____________________________________________
Parent printed name
_____________________________________________ _____________________________
Parent Signature Date
(ELECTRONIC SIGNATURES NOT ACCEPTED. Please print & sign in ink, then mail, fax, or scan and e-mail.)
