Fillable 2020-2021 NONCUSTODIAL PARENT STATEMENT (Occidental College)

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2020-2021 NONCUSTODIAL PARENT STATEMENT (Occidental College)

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This form is to be completed by the noncustodial parent (whether divorced, separated or never married). This form is used by the college to
evaluate the financial strength of the student’s noncustodial parent. Occidental College adheres to the principle that both parents, regardless of
their current marital status, have the primary responsibility for providing for their child’s education and should be expected to provide
reasonable financial support before college resources are used.
Complete the following chart and list ALL members of the household that you will support between July 1, 2020 and June 30, 2021.
Don't forget to include the student and yourself, the parent(s), as part of the household.
Name
Relationship
to Student
DOB
(MM/YYYY)
2020-2021
College/Univ
Attending
2020-2021
Year in
College
2020-2021
Enrollment
Status
Degree
Seeking
EXAMPLE:
Oswald Tiger
Student 01/2001 Oxy
2nd
Full-Time BA
EXAMPLE:
O. Tiger Sr.
Father 01/1965 N/A
N/A
N/A N/A
Only answer questions that apply to your family situation. Write “N/A” if a question does not apply.
Non-Custodial Parent(s)
Name of Non-Custodial Parent: _________________________ Name of Non-Custodial Step-Parent
_________________________
_________________________
Primary Residence
_________________________
_________________________
City, State, Zip
_________________________
_________________________
Telephone
_________________________
_________________________
$____________ 2018 Adjusted Gross Income (IRS Form 1040 line 7)
$____________ Wages, salaries, tips (IRS Form 1040 line 1 + Schedule 1)
$____________ Interest and dividend income (IRS Form 1040 2b)
$____________ Net income from business, farm, rents, royalties, partnerships, estates, trusts, etc.
(IRS Form 1040, lines 12, 17, and 18)
$____________ Other taxable income such as alimony received, capital gains (or losses), pensions, annuities, etc.
(IRS Form 1040 line 4b + Schedule 1 lines 10, 13, 14, 19, 21)
$____________ Adjustments to income (Schedule 1 line 36)
$____________ 2018 U.S. income tax paid (IRS 1040 line 13 - Schedule 2 line 46)
$____________ 2018 Itemized deductions (IRS 1040 line 8)
$____________ 2018 income earned from work by student’s noncustodial parent
$____________ 2018 income earned from work by noncustodial parent’s current spouse
E-mail
_________________________
TAXABLE INCOME
Please reference your 2018 tax return for answers to these questions.
PARENT PERSONAL INFORMATION
HOUSEHOLD SIZE
NONCUSTODIAL PARENT STATEMENT
2020-2021
STUDENT’S NAME:
OXY ID:
Occidental College
Financial Aid Office
1600 Campus Road F-35
Los Angeles, CA 90041
Phone: 323-259-2548
Fax: 323-341-4961
finaid@oxy.edu
www.oxy.edu/financial-aid
Primary Residence
City, State, Zip
Tel
ephone
E-mail
1. Provide amounts of all untaxed income that you, the non-custodial parent(s) received in 2018. If you did not have income from any of these
sources, please indicate $0.
IRA/SEP/SIMPLE/Keogh
Payments
$____________
$____________ Tax Deferred Pension Payments
$____________ Earned Income Credit
$____________ Tax-Exempt Interest Income
$____________ Foreign Income Exclusion
$____________ Social Security Benefits
$____________ Disability Benefits
$____________ Workman’s Compensation
$____________ Non-Educational VA Benefits
$____________ FSA Contributions
$____________ HSA Contributions
$____________ Living Allowance
(clergy/military)
$____________ Welfare Benefits
$____________ SNAP (aka Food Stamps)
$____________ TANF Benefits
$____________ Cash Support from Others
$____________ All Other Untaxed Benefits
2. Please list total child support you RECEIVED in 2018 for all children in your household:
Child #1 Child #2 Child #3 Child #4
Name of Child __________________ __________________ __________________ __________________
Amount of Annual Support $_________________ $_________________ $_________________ $__________________
Year Support will End __________________ __________________ __________________ __________________
Person Providing Support __________________ __________________ __________________ __________________
Report all assets held in the non-custodial parent(s) name(s) as of today’s date. If more than one property, business, or farm is owned,
please use a separate sheet of paper to itemize each property, business, or farm.
1. List all sources of cash, savings, and investments. Please do not list retirement accounts (e.g, 401K, 403B, IRA, tax sheltered annuities).
Source (e.g. inheritance, earnings, 529 accounts, gifts)
$______________ Cash, Savings & Checking ________________________________________________
$______________ Stocks & Bonds ________________________________________________
$______________ Trust Funds ________________________________________________
$______________ Other Securities/Investments ________________________________________________
2. Do you own the home where you reside?......................................NO YES
$______________ Current Market Value
$______________ Current Debt (include 1st & 2nd mortgages)
$______________ Purchase Price
_______________ Year Purchased
_______________ Percent Ownership
3. Do you own real estate other than the home where you reside? NO YES
$______________ Current Market Value
$______________ Current Debt
$______________ Purchase Price
_______________ Year Purchased
_______________ Percent Ownership (if owned less than 100%, only list your share of the market value and debt, not the total)
4. Do you own a business?...................................................................NO YES
______________________________ Type of Business
$______________ Current Market Value
$______________ Current Debt (not owed to yourself/shareholders)
$______________ Purchase Price
__
_____________ Year Purchased/Opened/Inherited
_______________ Percent Ownership
_______________ Number of Employees
If you file a corporate or partnership tax return for your business, you must submit a copy of the 2018 tax return to our office.
5. Do you own a farm?..........................................................................NO YES
______________________________ Type of Farm
$______________ Current Market Value
$______________ Current Debt (not owed to yourself/shareholders)
$______________ Purchase Price
_______________ Year Purchased/Opened/Inherited
_______________ Percent Ownership
If you own a farm, do you live on the farm for more than 50% of the year? NO YES
ASSETS
UNTAXED INCOME
Address of Property:
___________________________________
___________________________________
___________________________________
Address of Property:
___________________________________
___________________________________
___________________________________
Address of Business:
___________________________________
___________________________________
___________________________________
Address of Farm:
___________________________________
___________________________________
___________________________________
1. List the total amount of child support PAID in 2018 for all children:
Child #1 Child #2 Child #3 Child #4
Name of Child __________________ __________________ __________________ __________________
Amount of Annual Support __________________ __________________ __________________ __________________
Year Support will End $_________________ $_________________ $_________________ $_________________
Parent Who Received Support __________________ __________________ __________________ __________________
2. List the total amount of private elementary, junior high, or high school tuition paid in 2019-2020 academic year.
Child #1 Child #2 Child #3 Child #4
Name of Child __________________ __________________ __________________ __________________
Age of Child __________________ __________________ __________________ __________________
Amount of Tuition Paid $_________________ $_________________ $_________________ $_________________
Name of Private School __________________ __________________ __________________ __________________
Will this expense continue during the 2019-2020 academic year? NO YES
3. List the total amount of elder care expenses you paid in 2018. Only list support provided to elder family members who do not reside in your
home.
Person #1 Person #2 Person #3 Person #4
Name __________________ __________________ __________________ __________________
Age __________________ __________________ __________________ __________________
Annual Support $_________________ $_________________ $_________________ $_________________
Will this expense continue during the 2019-2020 academic year? NO YES
4. List the total amount of medical, dental, or vision expenses paid in 2018 that were not covered by insurance or otherwise reimbursed. Do
not include cost for insurance premiums paid.
Person #1 Person #2 Person #3 Person #4
Name of Family Member __________________ __________________ __________________ __________________
Amount of Medical Expenses Paid $_________________ $_________________ $_________________ $_________________
Type of Medical Expense __________________ __________________ __________________ __________________
Will this expense continue during the 2020-2021 academic year? NO
YES
5. List the total amount of educational loan payments made in 2019. This only includes higher education loans (such as a PLUS loan or if the
parent(s) is in repayment of their own student loans).
Loan #1 Loan #2 Loan #3 Loan #4
Name of Person Holding Loan __________________ __________________ __________________ __________________
Amount of Loan Paid $_________________ $_________________ $_________________ $_________________
Type of Loan __________________ __________________ __________________ __________________
Will this expense continue during the 2020-2021 academic year? NO
YES
I certify that all information reported on this form and any attachments and subsequent information provided to the Occidental College
Financial Aid Office is true, complete, and accurate to the best of my knowledge. I understand that if it is determined that I purposely
provided false or misleading information in an effort to receive federal financial aid, I may be fined, sentenced to jail, or both. This will also
be cause for referral (of the student) to the Judicial Council for possible violations of the Occidental College Code of Student Conduct.
The student and parent(s) may also be referred to the U.S. Department of Education Inspector General.
Parent Signature (no electronic signatures) Print Name
Date
CERTIFICATION
EXPENSES (OPTIONAL - Only complete if you have applicable special circumstances.)
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2020-2021 NONCUSTODIAL PARENT STATEMENT (Occidental College)

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Completed 24 August 2020

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