Student’s Name _______________________________________________ USF ID or SSN:______________________________________
You indicated on your application for financial aid that you are divorced, separated, or widowed and filed a joint 2018 IRS Tax Return. Complete
this form to clarify the division of income reported on your application. We have listed below the total income and adjustments reported on your
2018 IRS Income Tax Return Transcripts. Please note under student or spouse, the portion which would have been attributed to each of you had
you filed separately. Please be sure to include copies of the W2’s for you and your former spouse.
Adjustments to income
Medical savings account deductions
Moving expenses
One-half self-employment’s tax
Self-employed health insurance
Keogh, and self-employed SEP or SIMPLE Plans
Penalty on early withdrawal of savings
IRA deduction
Student loan interest deduction
Other adjustments to income
Adjusted Gross Income
I certify that this information is correct and that I am providing, or have provided, a complete copy of my 2018 IRS Income Tax
Transcript and W2 Wage documents for both student and former spouse.
_______________________________________________ ______________________
Student’s Signature Date
Please return the completed form to:
Financial Aid Services
500 Wilcox Street Joliet, IL 60435 | finaid@stfrancis.edu
(815) 740-3403 | Toll-free: (866) 890-8331 | Fax: (815) 740-3822
div of income - indep
Item on Income Tax Return
Total on Return
Wages, salaries, tips, etc.
Taxable interest
Tax-exempt Interest
Dividend income
Taxable refunds of state and local Income taxes
Alimony received
Business income or loss
Capital gain or loss
Other gains or loss
Total taxable IRA distributions
Tax exempt IRA distributions
Total Taxable pension/annuities
Tax exempt pension/annuities
Rents, royalties, partnership, S Corp., estates Trusts, etc.
Farm income or loss
Unemployment compensation
Taxable social security benefits
Tax-exempt social security benefits
Other income
click to sign
click to edit