Scholarship
Dnd
AwarGs
ProgrDm
2022
ABOUT THE PROGRAM
2005 was the first year the CDA Scholarship Foundation
was able to award grants to qualifying children of the
CDA Membership. Since its inception, we have been able
to increase the amount awarded every year. This year,
we expect to continue th
e program and are hopeful that
we will have more contributing sponsors.
The CDA Scholarship Foundation welcomes applications
from member-employee children and will award
meaningful scholarship grants that demonstrate a need
for assistance through the Federal Government FAFSA
Application.
In addition, the CDA Scholarship Committee will select
one Merit Candidate to receive the "6KLHOGV)DPLO\
0HULW$ZDUG This award will be given annually to D
graduating high school senior who has a superior
academic record and has demonstrated real interest in
a business career.
For more information, please contact the CDA through
your company’s Human Resources Department or
via email to Lisa Ghatan at LGhatan@myLDI.com
via postal mail: CDA Scholarship Program
c/o LDI Connect
Attn: Lisa Ghatan
50 Jericho Quadrangle Suite 115
Jericho NY 11753
About the CDA
The CDA consists of approximately 80 successful business
owners from the United States, Canada, and Europe who
come together to pool business knowledge and share
business strategies. Originally, the respective member
companies dealt primarily with the copier industry, but
today, topics include connected products, document
imaging, network support, and much more. CDA has earned
a national and international reputation as being comprised
of the most successful business owners representing
products and services on the leading edge of business
technology.
CDA is a vehicle through which the exchange of ideas and
concepts works for the improvement of all its members. It
provides members with a resource network for finding
solutions to today's business challenges and for comparing
financial benchmarks on a dealer-dealer level. CDA invites
several guest speakers to each meeting, ranging from
industry analysts and marketing experts to specialists in
business management, helath insurance and legal issues.
YOU - APPLICANT
1. Name in full (please print)
(last) (first) (middle)
2. Permanent home address
(street and number) (town/city) (state) (zip)
3. Home telephone or number where you can be reached ____________________ Cell number ____________________
4. Email Address
5. If your mailing address is different from your permanent home address, please fill in the next two lines
Present mailing address
(street and number) (town/city) (state) (zip)
Present mailing address is effective until
(date)
6. Date of Birth Age last birthday
(month) (day) (year)
7. Place of birth
(town/city) (state) (country)
8. Citizenship: US Other
(please name country)
YOUR FAMILY
1. CDA Member Parent's Full Name
2. CDA Member Parent's Home Address
The questions in this form are designed to collect information about your background, your interests, and your
plans. Your answers to these questions will be used only in connection with your application in this Student Aid
program and will be divulged only to qualified persons who must see them in the course of their duties.
Please use a black pen and write legibly. Do not use pencil.
PAGE 1
3. CDA Member Parent's Occupation: Be specific.
4. Name of CDA member organization for which he/she works
5. Address of CDA member organization for which he/she works
6. Telephone number of CDA member organization for which he/she works
7. Name of parent or guardian who supports you
Address:
Relationship to you Occupation
YOUR SCHOOLING AND ACTIVITIES
1. List in chronological order all schools attended in the last five years.
8. If you have listed the name of someone other than your father or mother as the person who supports you, please
give the following information about him/her:
Dates of AttendanceLocationName of School
2. List your extracurricular activities (not more than 4 and excluding jobs) during the past three years, in order of
their interest for you. (Example: student government, dramatics, athletics, debating, publications, orchestra, Boy or
Girl Scouts, 4-H Club, Red Cross, church groups, etc.)
Activity Position held
PAGE 2
3. List any distinctions you have won, scholastic or otherwise
4. List work and vacation experience during the past three years.
9th grade School Year
Summer
10th grade School Year
Summer
11th grade School Year
Summer
YOUR COLLEGE OR OTHER EDUCATIONAL PLANS
1. To which colleges or institutions have you made application? List in order of preference.
2. If one of the above schools is within commuting distance, do you plan to live at home?
live at school?
Total Amount EarnedEmployerActivity or Job
5. State briefly how you would plan to spend this coming summer. If you plan to work, how much do you expect to
earn?
If you have been
accepted, checkName Address Course (Major)
PAGE 3
3. Have you completed or are planning to compete in any national, state or other scholastic contests?
4. (a) Have you applied for financial aid? Yes No
If yes, please indicate:
(b) If not, why not?
5. If you are only applying as a Merit Candidate to receive the "Shields Family Merit Award" please check here
REQUIRED ESSAY
Please check carefully to make sure that you have answered this questionnaire completely.
DEADLINE FOR APPLICATION SUBMISSION: Friday, MAY 6, 2022
Please send completed application to: CDA Scholarship Program
via email: LGhatan@myLDI.com
via fax: 516.496.4595 Attn: Lisa Ghatan
via mail: CDA Scholarship c/o LDI Connect 50 Jericho Quadrangle, Jericho NY 11753
Attn: Lisa Ghatan
Result, if knownName
Institution Amount
Pl
Please provide a 500 word essay describing your future goals and what might set you apart from other potential applicants.
All applications must include a completed FAFSA form. Incomplete applications will NOT be considered.
Applicants SignatureDate
PAGE 4
A
( )
Step One (Student):
For questions 1-31, leave any questions that do not apply to you (the student) blank.
Male
Register me
Female
1
2
1
Yes
No
1
3
Middle school/Jr. high Other/unknown
High school
College or beyond
1 2 3 4
1
2
3 4
STATE
No
Yes
1
2
MONTH YEAR
3
4
1
2
High school diploma. Answer question 27. ...............................................
None of the above. Skip to question 28. .......
General Educational Development (GED) certicate or state certicate. Skip to question 28.
Homeschooled. Skip to question 28.
..........
No, but I am an eligible noncitizen. Fill in question 15. ..........
2
No, I am not a citizen or eligible noncitizen. Skip to question 16.
3
Yes, I am a U.S. citizen (U.S. national). Skip to question 16. ......
1
MONTH YEAR
I am separated . . . . . . . . . . .
I am married/remarried
I am single . . . . . . . . . . . . .
I am divorced or widowed
3
4
1
2
16. What is your
marital status as
of today?
See Notes page 9.
3. Middle
initial
6. State
7. ZIP code
8. Your Social Security Number See Notes page 9.
10. Your telephone number
4. Number and street
(include apt. number)
5. City (and country if
not U.S.)
Your driver’s license number and driver’s license state (if you have one)
12. Driver’s license
state
11. Driver’s license
number
13. Your e-mail address. If you provide your e-mail address, we will communicate with you electronically. For example, when your FAFSA form has been processed, you
will be notied by e-mail. Your e-mail address will also be shared with your state and the colleges listed on your FAFSA form to allow them to communicate with you. If
you do not have an e-mail address, leave this eld blank.
22. If female, skip to question 23.
Most male students must register with the Selective
Service System to receive federal aid. If you are male, are age 18-25, and have not
registered, ll in the circle and we will register you. See Notes page 9.
21. Are you male or
female?
See Notes page 9.
23. Have you been convicted for the possession or sale of illegal drugs for an oense that occurred while you were receiving federal
student aid (such as grants, work-study, or loans)?
Answer “No” if you have never received federal student aid or if you have never had a drug conviction for an oense that occurred while receiving
federal student aid. If you have a drug conviction for an oense that occurred while you were receiving federal student aid, answer “Yes,” but
complete and submit this application, and we will mail you a worksheet to help you determine if your conviction aects your eligibility for aid.
If you are unsure how to answer this question, call 1-800-433-3243 for help.
19. Did you become a legal
resident of this state
before January 1, 2016?
20. If the answer to question 19 is “No,”
give month and year you became a
legal resident of that state.
18. What is your
state of legal
residence?
14. Are you a U.S.
citizen?
Mark only one.
See Notes page 9.
15. Alien Registration Number
17. Month and year you were married,
remarried, separated, divorced or
widowed.
See Notes page 9.
26. What will your high school completion status be when you begin college in the 2021-2022 school year?
1. Last
name
2. First
name
Your full name (exactly as it appears on your Social Security card) If your name has a sux, such as Jr. or III, include a space between your last name and sux.
Some states and colleges oer aid based on the level of schooling your parents completed.
Your permanent mailing address
9. Your date
of birth
MONTH YEARDAY
24. Highest school completed by Parent 1
25. Highest school completed by Parent 2
Middle school/Jr. high Other/unknown
High school
College or beyond
Answer questions 32–57 about yourself (the student). If you were never married, or are separated,
divorced or widowed and are not remarried, answer only about yourself. If you are married or remarried
as of today, include information about your spouse.
Step Two (Student):
For questions 36–44, if the answer is zero or the question does not apply to you, enter 0. Report whole dollar amounts with no cents.
9
Other/undecided .........................................................
8
College graduate or professional degree (MBA, MD, PhD, etc.) ..............
7
Teaching credential (nondegree program) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
Associate degree (occupational or technical program) .....................
2nd bachelor’s degree ....................................................
2
1
1st bachelor’s degree .....................................................
6
Certicate or diploma (occupational, technical or education program
of two or more years) .....................................................
5
Certicate or diploma (occupational, technical or education program
of less than two years). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4
Associate degree (general education or transfer program). . . . . . . . . . . . . . . . . .
4
4th year undergraduate/senior . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6
1st year college graduate/professional (MBA, MD, PhD, etc.) . . . . . . . . .
5
5th year/other undergraduate. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3
3rd year undergraduate/junior .....................................
2
2nd year undergraduate/sophomore . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
1
Attended college before and 1st year undergraduate ...............
0
Never attended college and 1st year undergraduate ................
7
Continuing graduate/professional or beyond (MBA, MD, PhD, etc.) . .
29. What will your college grade level be when you begin the
2021-2022 school year?
30. What college degree or certicate will you be working on when you
begin the 2021-2022 school year?
40. As of today, what is your (and spouse’s) total current balance of cash, savings, and checking accounts? Don’t include
student nancial aid.
41. As of today, what is the net worth of your (and spouse’s) investments, including real estate? Don’t include the home
you live in.
See Notes page 9.
42. As of today, what is the net worth of your (and spouse’s) current businesses and/or investment farms? Don’t include a
family farm or family business with 100 or fewer full-time or full-time equivalent employees. See Notes page 9.
36. What was your (and spouse’s) adjusted gross income for 2019? Adjusted gross income is on IRS Form 1040—line 8b.
37. Enter your (and spouse’s) income tax for 2019. Income tax amount is the total of IRS Form 1040—line 14 minus
Schedule 2—line 2. If negative, enter a zero here.
NoYes Don’t know
1
3
2
35. Did (or will) you le a Schedule 1 with your 2019 tax return? Answer No if you did not le a Schedule 1
or only led a Schedule 1 to report: unemployment compensation, educator expenses, IRA deduction,
student loan interest deduction, Alaska Permanent Fund dividend, or virtual currency. See Notes page 9.
38. How much did you earn from working in 2019?
39. How much did your spouse earn from working in 2019?
Questions 38 and 39 ask about earnings (wages, salaries, tips, etc.) in 2019. Answer the questions whether or not a tax return was led. This information
may be on the W-2 forms or on the tax return selected in question 33: IRS Form 1040—line 1 + Schedule 1—lines 3 + 6 + Schedule K-1 (IRS Form 1065)—
Box 14 (Code A). If any individual earning item is negative, do not include that item in your calculation.
NoYes Don’t know
2
3
1
31. Are you interested in being considered for work-study?
1
Yes No
2
28. Will you have your rst bachelor’s degree
before you begin the 2021-2022 school
year?
27. What is the name of the high school where you received or will receive your high school diploma?
Enter the complete high school name, and the city and state where the high school is located.
STATE
High School Name
High School City
1
IRS 1040 ..........................................
3
A foreign tax return, IRS 1040NR or IRS 1040NR-EZ.
See Notes page 9. ...............................
4
A tax return with Puerto Rico, another U.S. territory,
or Freely Associated State. See Notes page 9. . . . . .
1
I have already completed my return .......
3
I’m not going to le. Skip to question 38.
2
I will le but have not yet completed my
return .....................................
32. For 2019, have you (the student) completed
your IRS income tax return or another tax
return listed in question 33?
33. What income tax return did you le or will you le
for 2019?
1
Single ...............................
3
Married—led separate return .......
2
Married—led joint return ...........
34. For 2019, what is or will be your tax ling
status according to your tax return?
6
Don’t know ..........................
5
Qualifying widow(er). . . . . . . . . . . . . . . . .
4
Head of household. . . . . . . . . . . . . . . . . . .
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
$
,
,
Step Three (Student):
No
1
Yes
2
No
1
Yes
2
Step Two CONTINUES from Page 4
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
No
21
Yes
Answer the questions in this step to determine if you will need to provide parental information. Once
you answer “Yes” to any of the questions in this step, skip Step Four and go to Step Five on page 8.
a. 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
forms in Boxes 12a
through
12d, codes D, E, F, G, H and S. Don’t include amounts reported in code DD
(employer contributions toward employee health benets).
b. IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualied plans from IRS Form 1040 Schedule 1—total
of lines 15 + 19.
c. Child support received for any of your children. Don’t include foster care or adoption payments.
d.
Tax
exempt interest income from IRS
Form 1040—line 2a.
e. Untaxed portions of IRA distributions and pensions from IRS Form 1040—(lines 4a + 4c) minus (lines 4b + 4d). Exclude rollovers. If
negative, enter a zero here.
f. Housing, food and other living allowances paid to members of the military, clergy and others (including cash payments and cash value
of benets). Don’t include the value of on-base military housing or the value of a basic military allowance for housing.
g. Veterans noneducation benets, such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA
Educational Work-Study allowances.
h. Other untaxed income not reported in items 44a through 44g, such as workers compensation, disability benets, untaxed foreign
income, etc. Also include the untaxed portions of health savings accounts from IRS F
orm 1040 Schedule 1—line 12. Don’t include
extended foster care benets, student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social Security
benets, Supplemental Security Income, Workforce Innovation and Opportunity Act educational benets, on-base military housing
or a military housing allowance, combat pay, benets from exible spending arrangements (e.g., cafeteria plans), foreign income
exclusion or credit for federal tax on special fuels.
i. 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 nancial information is not reported on this form and that is not part of a legal child support agreement.
See Notes page 9.
a. Education credits (American Opportunity Tax Credit and Lifetime Learning Tax Credit) from IRS Form 1040 Schedule 3—line 3.
b. 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 in question 93.
c. Taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment portions of
fellowships and assistantships.
d. Taxable college grant and scholarship aid reported to the IRS as income. Includes AmeriCorps benets (awards, living allowances and
interest accrual payments), as well as grant and scholarship portions of fellowships and assistantships.
e.
Combat pay or special combat pay. Only enter the amount that was taxable and included in your adjusted gross income. Don’t include
untaxed combat pay.
f. Earnings from work under a cooperative education program oered by a college.
45. Were you born before January 1, 1998? ................................................................................
46. As of today, are you married? (Also answer “Yes” if you are separated but not divorced.) .................................
47. At the beginning of the 2021-2022 school year, will you be working on a master’s or doctorate program (such as an MA,
MBA, MD, JD, PhD, EdD, graduate certicate, etc.)?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
48. Are you currently serving on active duty in the U.S. Armed Forces for purposes other than training?
See Notes page 9. ....
49. Are you a veteran of the U.S. Armed Forces? See Notes page 9. ...........................................................
50. Do you now have or will you have children who will receive more than half of their support from you between July 1, 2021
and June 30, 2022?. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
51. Do you have dependents (other than your children or spouse) who live with you and who receive more than half of their
support from you, now and through June 30, 2022?
....................................................................
52. At any time since you turned age 13, were both your parents deceased, were you in foster care or were you a dependent
or ward of the court?
See Notes page 10. ................................................................................
53. As determined by a court in your state of legal residence, are you or were you an emancipated minor? See Notes page 10. ..
54. Does someone other than your parent or stepparent have legal guardianship of you, as determined by a court in your state
of legal residence?
See Notes page 10. ..................................................................................
55. At any time on or after July 1, 2020, did your high school or school district homeless liaison determine that you were an
unaccompanied youth who was homeless or were self-supporting and at risk of being homeless?
See Notes page 10. . . . . .
56. At any time on or after July 1, 2020, did the director of an emergency shelter or transitional housing program funded by
the U.S. Department of Housing and Urban Development determine that you were an unaccompanied youth who was
homeless or were self-supporting and at risk of being homeless?
See Notes page 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
57. At any time on or after July 1, 2020, did the director of a runaway or homeless youth basic center or transitional living
program determine that you were an unaccompanied youth who was homeless or were self-supporting and at risk of
being homeless?
See Notes page 10. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
44. Student’s 2019 Untaxed Income (Enter the combined amounts for you and your spouse.)
43. Student’s 2019 Additional Financial Information (Enter the combined amounts for you and your spouse.)
l i
1
3
4
2
3
1
1
3
2
6
5
4
Step Four (Parent):
Complete this step if you (the student) answered “No” to all questions in Step Three.
Answer all the questions in Step Four even if you do not live with your legal parents (biological, adoptive, or as determined by the state [for example, if the parent is listed
on the birth certicate]). Grandparents, foster parents, legal guardians, widowed stepparents, aunts, uncles, and siblings are not considered parents on this form unless they
have legally adopted you. If your legal parents are married to each other, or are not married to each other and live together, answer the questions about both of them. If
your parent was never married or is remarried, divorced, separated or widowed, see StudentAid.gov/fafsa-parent and/or Notes page 10 for additional instructions.
68. Your parents’ e-mail address. If you provide your parents’ e-mail address, we will let them know your FAFSA form has been processed. This e-mail address will
also be shared with your state and the colleges listed on your FAFSA form to allow them to electronically communicate with your parents.
72. How many people are in your parents’ household?
Include:
• yourself, even if you don’t live with your parents,
• your parents,
• your parents’ other children (even if they do not live with your parents) if (a) your parents will provide more than half of their support
between July 1, 2021 and June 30, 2022, or
(b) the children could answer “No” to every question in Step Three on page 5 of this form, and
• other people if they now live with your parents, your parents provide more than half of their support and your parents will continue to
provide more than half of their support between July 1, 2021 and June 30, 2022.
73. How many people in your parents’ household (from question 72) will be college students between July 1, 2021 and June 30, 2022?
Always count yourself as a college student. Do not include your parents. Do not include siblings who are in U.S. military service academies. You
may include others only if they will attend, at least half-time in 2021-2022, a program that leads to a college degree or certicate.
At any time during 2019 or 2020, did you, your parents, or anyone in your parents’ household (from question 72) receive benets from any of the federal programs listed?
Mark all that apply. Answering these questions will NOT reduce eligibility for student aid or these programs. TANF has dierent names in many states. Call 1-800-433-3243
to nd out the name of your state’s program. If you, your parents, or anyone in your household receives any of these benets after ling the FAFSA form but before
December 31, 2020, you must update your response by logging in to fafsa.gov and selecting “Make FAFSA Corrections.”
74. Medicaid or
Supplemental
Security Income (SSI)
75. Supplemental
Nutrition Assistance
Program (SNAP)
76. Free or Reduced
Price School
Lunch
77. Temporary Assistance
for Needy Families
(TANF)
78. Special Supplemental Nutrition
Program for Women, Infants,
and Children (WIC)
69. What is your
parents’ state of
legal residence?
70. Did your parents become
legal residents of this state
before January 1, 2016?
71. If the answer to question 70 is “No,” give the
month and year legal residency began for the
parent who has lived in the state the longest.
MONTH YEAR
STATE
No
Yes
1
82. Did (or will) your parents le a Schedule 1 with their 2019 tax return? Answer No if
they did not le a Schedule 1 or only led a Schedule 1 to report: unemployment
compensation, educator expenses, IRA deduction, student loan interest deduction,
Alaska Permanent Fund dividend, or virtual currency.
See Notes page 9.
2
83. As of today, is either
of your parents a
dislocated worker?
See Notes page 10.
No
Yes
Don’t know
No
Yes
Don’t know
1
2
3
1
2
3
81. For 2019, what is or will be your parents tax
ling status according to their tax return?
58. As of today, what is the marital status of your parents? 59. Month and year
they were married,
remarried, separated,
divorced or widowed.
Divorced or separated
...............
Married or remarried
. . . . . . . . . . . . . . . .
Never married
. . . . . . . . . . . . . . . . . . . . . . . .
MONTH YEAR
Widowed
. . . . . . . . . . . . . . . . . . . . . . . . . .
12
3
4
If
you (the student) answered
“No”
to every
question
in Step Three, go to Step
Four.
If
you answered
“Yes”
to any
question
in Step Three, skip Step Four and go to Step Five on page
8.
(Health professions and law school students:
Your
college may require you to complete Step Four even
if
you answered
“Yes”
to any Step Three
question.)
If you believe that you are unable to provide parental information, see Notes page 10.
What are the Social Security Numbers, names and dates of birth of the parents reporting information on this form? If your parent does not have a Social Security
Number, you must enter 000-00-0000. Don’t enter an Individual Taxpayer Identication Number (ITIN) in the Social Security Number eld. If the name includes a sux,
such as Jr. or III, include a space between the last name and sux. Enter two digits for each day and month (e.g., for May 31, enter 05 31).
60. SOCIAL SECURITY NUMBER
61. LAST NAME, AND
62. FIRST INITIAL
63. DATE OF BIRTH
64. SOCIAL SECURITY NUMBER 65. LAST NAME, AND
66. FIRST INITIAL
67. DATE OF BIRTH
,
,
Questions 60-63 are for Parent 1 (father/mother/stepparent)
Questions 64-67 are for Parent 2 (father/mother/stepparent)
Unmarried and both legal parents living
together.
............................
5
If your answer to question 58 was “Unmarried and both legal parents living together,” contact 1-800-433-3243 for help with questions 79-92.
Single ..............................
Married—led separate return ......
Married—led joint return ..........
Don’t know .........................
Qualifying widow(er). . . . . . . . . . . . . . . .
Head of household. . . . . . . . . . . . . . . . . .
80. What income tax return did your parents
le or will they le for 2019?
IRS 1040 ...................................
A foreign tax return, IRS 1040NR or IRS
1040NR-EZ. See Notes page 9. ............
A tax return with Puerto Rico, another U.S.
territory or Freely Associated State.
See Notes page 9. ........................
79. For 2019, have your parents completed their IRS
income tax return or another tax return listed in
question 80?
My
parents will le but have not yet completed
their
return .....................................
My
parents are not going to le.
Skip to
question
86. . . . . . . . . . . . . . . . . . . . . . . . . . . .
My
parents have already completed their return.
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,
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$
,
,
86. How much did Parent 1 (father/mother/stepparent) earn from working in 2019?
87. How much did Parent 2 (father/mother/stepparent) earn from working in 2019?
Questions 86 and 87 ask about earnings (wages, salaries, tips, etc.) in 2019. Answer the questions whether or not a tax return was led. This information may be on the W-2
forms or on the tax return selected in question 80: IRS Form 1040—line 1 + Schedule 1lines 3 + 6 + Schedule K-1 (IRS Form 1065)Box 14 (Code A). If any individual
earning item is negative, do not include that item in your calculation. Report the information for the parent listed in questions 60-63 in question 86 and the information for
the parent listed in questions 64-67 in question 87.
For questions 84–92, if the answer is zero or the question does not apply, enter 0. Report whole dollar amounts with no cents.
Step Four CONTINUES from Page 6
88. As of today, what is your parents’ total current balance of cash, savings, and checking accounts?
Don’t include student
nancial aid.
89. As of today, what is the net worth of your parents’ investments, including real estate? Don’t include the home in which
your parents live.
See Notes page 9.
90. As of today, what is the net worth of your parents’ current businesses and/or investment farms? Don’t include a family
farm or family business with 100 or fewer full-time or full-time equivalent employees. See Notes page 9.
84. What was your parents’ adjusted gross income for 2019? Adjusted gross income is on IRS Form 1040—line 8b.
85. Enter your parents’ income tax for 2019. Income tax amount is the total of IRS Form 1040—line 14 minus
Schedule 2—line 2. If negative, enter a zero here.
a. Education credits (American Opportunity Tax Credit and Lifetime Learning Tax Credit) from IRS Form 1040 Schedule 3—line 3.
b. Child support paid because of divorce or separation or as a result of a legal requirement. Don’t include support for children in your
parents’ household, as reported in question 72.
c. Your parents’ taxable earnings from need-based employment programs, such as Federal Work-Study and need-based employment
portions of fellowships and assistantships.
d. Y
our parents’ taxable college grant and scholarship aid reported
to
the
IRS
as
income
. I
ncludes A
mer
iCorps benets (awards, living
allowances and interest accrual payments), as well as grant and scholarship portions of fellowships and assistantships.
e. Combat pay or special combat pay. Only enter the amount that was taxable and included in your parents’ adjusted gross income.
Don
t include
untaxed combat pay.
f. Earnings from work under a cooperative education program oered by a college.
a. 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 forms in Boxes 12a through 12d, codes D, E, F, G, H and S. Don’t include amounts reported in code
DD (employer contributions toward employee health benets).
b. IRA deductions and payments to self-employed SEP, SIMPLE, Keogh and other qualied plans from IRS Form 1040 Schedule 1—total
of lines 15 + 19.
c. Child support received for any of your parents’ children. Don’t include foster care or adoption payments.
d. Tax exempt interest income from IRS Form 1040—line 2a.
e. Untaxed portions of IRA distributions and pensions from IRS Form 1040—(lines 4a + 4c) minus (lines 4b + 4d). Exclude rollovers. If
negative, enter a zero here.
f. Housing, food and other living allowances paid to members of the military, clergy and others (including cash payments and cash
value of benets). Don’t include the value of on-base military housing or the value of a basic military allowance for housing.
g. Veterans noneducation benets, such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA
Educational Work-Study allowances.
h. Other untaxed income not reported in items 92a through 92g, such as workers’ compensation, disability benets, untaxed foreign
income, etc. Also include the untaxed portions of health savings accounts from IRS Form 1040 Schedule 1—line 12. Don’t include
extended foster care benets, student aid, earned income credit, additional child tax credit, welfare payments, untaxed Social
Security benets, Supplemental Security Income, Workforce Innovation and Opportunity Act educational benets, on-base military
housing or a military housing allowance, combat pay, benets from exible spending arrangements (e.g., cafeteria plans), foreign
income exclusion or credit for federal tax on special fuels.
91. Parents’ 2019 Additional Financial Information (Enter the
amounts
for your
parent[s].)
92. Parents’ 2019 Untaxed Income (Enter the
amounts
for your
parent[s].)
2021-2022
1
– –
1
2
Step Five (Student):
Complete this step only if you (the student) answered “Yes” to any questions in Step Three.
Step Six (Student):
Indicate which colleges you want to receive your FAFSA information.
Step Seven (Student and Parent):
Read, sign and date.
on campus
o campus
with parent
101. a
101. c
101. e
101. g
101. b
101. d
101. f
101. h
OR
OR
OR
OR
STATE
STATE
STATE
STATE
NAME OF
COLLEGE
NAME OF
COLLEGE
NAME OF
COLLEGE
NAME OF
COLLEGE
ADDRESS
AND CITY
ADDRESS
AND CITY
ADDRESS
AND CITY
ADDRESS
AND CITY
1ST FEDERAL SCHOOL CODE
2ND FEDERAL SCHOOL CODE
3RD FEDERAL SCHOOL CODE
4TH FEDERAL SCHOOL CODE
104. Preparer’s Social Security Number (or 105)
105. Employer ID number (or 104)
106. Preparer’s signature and date
COLLEGE USE ONLY
D/O
FEDERAL SCHOOL CODE
FAA Signature
DATA ENTRY
USE ONLY:
P * L E
If a fee was paid to someone for advice or
for completing this form, that person must
complete this section.
Preparer’s name, rm and address
1
1
on campus
o campus
with parent
on campus
o campus
with parent
on campus
o campus
with parent
NoYes Don’t know
2
3
1
1
2
3
1
2
3
1
2
3
1
2
3
Homeless
Youth
Determination
4
93. How many people are in your household?
Include:
• yourself (and your spouse),
• your children, if you will provide more than half of their support between July 1, 2021 and June 30, 2022, even if they do not live with you, and
• other people if they now live with you, you provide more than half of their support and you will continue to provide more than half of their
support between July 1, 2021 and June 30, 2022.
94. How many people in your (and your spouse’s) household (from question 93) will be college students between July 1, 2021
and June 30, 2022? Always count yourself as a college student. Do not include family members who are in U.S. military service academies.
Include others only if they will attend, at least half-time in 2021-2022, a program that leads to a college degree or certicate.
At any time during 2019 or 2020, did you (or your spouse) or anyone in your household (from question 93) receive benets from any of the federal programs listed?
Mark all that apply. Answering these questions will NOT reduce eligibility for student aid or these programs. TANF has dierent names in many states. Call 1-800-433-3243
to nd out the name of your state’s program. If you (or your spouse) or anyone in your household receives any of these benets after ling the FAFSA form but before
December 31, 2020, you must update your response by logging in to fafsa.gov and selecting “Make FAFSA Corrections.”
100. As of today, are you (or your spouse) a dislocated worker? See Notes page 10.
Enter the six-digit federal school code and your housing plans for each college or school you want to receive your FAFSA information. You can nd the
school codes at fafsa.gov/schoolsearch or by calling 1-800-433-3243. If you cannot obtain a code, write in the complete name, address, city and state of
the college. If you want more schools to receive your FAFSA information, read What is the FAFSA form? on page 2. All of the information you included on
your FAFSA form, with the exception of the list of colleges, will be sent to each of the colleges you listed. In addition, all of your FAFSA information, including
the list of colleges, will be sent to your state grant agency. For federal student aid purposes, it does not matter in what order you list your selected schools.
However, the order in which you list schools may aect your eligibility for state aid. Consult your state agency or StudentAid.gov/order for details.
2022
MONTH DAY
102. Date this form was completed
103. Student (Sign below)
Parent (A parent from Step Four sign below.)
If you are the student, by signing this application you certify that you (1) will use federal and/or state
student nancial aid only to pay the cost of attending an institution of higher education, (2) are not
in default on a federal student loan or have made satisfactory arrangements to repay it, (3) do not
owe money back on a federal student grant or have made satisfactory arrangements to repay it, (4)
will notify your college if you default on a federal student loan and (5) will not receive a Federal Pell
Grant from more than one college for the same period of time.
If you are the parent or the student, by signing this application you certify that all of the information
you provided is true and complete to the best of your knowledge and you agree, if asked, to
provide information that will verify the accuracy of your completed form. This information may
include U.S. or state income tax forms that you led or are required to le. Also, you certify that
you understand that the Secretary of Education has the authority to verify information
reported on this application with the Internal Revenue Service and other federal agencies. If
you electronically sign any document related to the federal student aid programs using an FSA ID
(username and password) and/or any other credential, you certify that you are the person identied
by that username and password and/or other credential, and have not disclosed that username
and password and/or other credential to anyone else. If you purposely give false or misleading
information, you may be ned up to $20,000, sent to prison, or both.
HOUSING PLANS
2021
2020
95. Medicaid or
Supplemental
Security Income (SSI)
96. Supplemental
Nutrition Assistance
Program (SNAP)
97. Free or Reduced
Price School
Lunch
98. Temporary Assistance
for Needy Families
(TANF)
99. Special Supplemental Nutrition
Program for Women, Infants,
and Children (WIC)
Notes for question 8 (page 3)
Enter your Social Security Number (SSN) as it appears on your Social
Security card. If you are a resident of one of the Freely Associated
States (i.e., the Republic of Palau, the Republic of the Marshall Islands,
or the Federated States of Micronesia) and were issued an identication
number beginning with “666” when submitting a FAFSA form previously,
enter that number here. If you are a rst-time applicant from one of the
Freely Associated States, enter “666” in the rst three boxes of the Social
Security Number eld and leave the remaining six positions blank, and
we will create an identication number to be used for federal student
aid purposes. Do not enter an Individual Taxpayer Identication Number
(ITIN) in the Social Security Number eld.
Notes for questions 14 and 15 (page 3)
If you are an eligible noncitizen, write in your eight- or nine-digit Alien
Registration Number. Generally, you are an eligible noncitizen if you are
(1) a permanent U.S. resident with a Permanent Resident Card (I-551); (2)
a conditional permanent resident with a Conditional Green Card (I-551C);
(3) the holder of an Arrival-Departure Record (I-94) from the Department
of Homeland Security showing any one of the following designations:
“Refugee,” “Asylum Granted,” “Parolee” (I-94 conrms that you were
paroled for a minimum of one year and status has not expired), T-Visa
holder (T-1, T-2, T-3, etc.) or “Cuban-Haitian Entrant;” or (4) the holder of
a valid certication or eligibility letter from the Department of Health and
Human Services showing a designation of “Victim of human tracking.”
If you are in the U.S. and have been granted Deferred Action for Childhood
Arrivals (DACA), an F1 or F2 student visa, a J1 or J2 exchange visitor visa,
or a G series visa (pertaining to international organizations), select “No, I
am not a citizen or eligible noncitizen.” You will not be eligible for federal
student aid. If you have a Social Security Number but are not a citizen
or an eligible noncitizen, including if you have been granted DACA, you
should still complete the FAFSA form because you may be eligible for
state or college aid.
Notes for questions 16 and 17 (page 3)
Report your marital status as of the date you sign your FAFSA form. If
your marital status changes after you sign your FAFSA form, check with
the nancial aid oce at the college.
Notes for questions 21 and 22 (page 3)
To be eligible for federal student aid, male citizens and male immigrants
residing in the U.S. aged 18 through 25 are required to register with the
Selective Service System, with limited exceptions. The Selective Service
System and the registration requirement applies to any person assigned the
sex of male at birth (see www.sss.gov/Registration-Info/Who-Registration).
The Selective Service System and the registration requirement for males
preserves America’s ability to provide resources in an emergency to the U.S.
Armed Forces. For more information about the Selective Service System, visit
sss.gov. Forms are available at your local U.S. Post Oce.
Notes for questions 33 (page 4)
and 80 (page 6)
If you led or will le a foreign tax return, IRS 1040NR or IRS 1040NR-EZ, or
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 ll out this form. If you led a foreign return, convert all
monetary units to U.S. dollars, using the published exchange rate in eect
for the date nearest to today’s date. To view the daily exchange rates, go to
federalreserve.gov/releases/h10/current.
Notes for questions 35 (page 4)
and 82 (page 6)
Answer “No if you (and if married, your spouse) did not le a Schedule 1.
Answer “No if you (and if married, your spouse) did or will le a Schedule 1
to report only one or more of the following items:
1. Unemployment compensation (line 7)
2. Other income to report an Alaska Permanent Fund dividend (line 8 –
may not be a negative value)
3. Educator expenses (line 10)
4. IRA deduction (line 19)
5. Student loan interest deduction (line 20)
6. Receiving, selling, sending, exchanging, or otherwise acquiring any
nancial interest in any virtual currency
Answer “Yes if you (or if married, your spouse) led or will le a Schedule 1
and reported additional income or adjustments to income on any lines
other than or in addition to the six exceptions listed above.
If you do not know if you led or will le a Schedule 1, select Don’t know.”
Notes for questions 41 and 42 (page 4), 44i (page 5),
and 89 and 90 (page 7)
Net worth means the current value, as of today, of investments,
businesses, and/or investment farms, minus debts related to those same
investments, businesses, and/or investment farms. When calculating net
worth, use 0 for investments or properties with a negative value.
Investments include real estate (do not include the home in which you
live), rental property (includes a unit within a family home that has its
own entrance, kitchen, and bath rented to someone other than a family
member), trust funds, UGMA and UTMA accounts, money market funds,
mutual funds, certicates of deposit, stocks, stock options, bonds, other
securities, installment and land sale contracts (including mortgages
held), commodities, etc.
Investments also include qualied educational benets or education
savings accounts (e.g., Coverdell savings accounts, 529 college savings
plans and the refund value of 529 prepaid tuition plans). For a student
who does not report parental information, the accounts owned by the
student (and/or the student’s spouse) are reported as student investments
in question 41. For a student who must report parental information, the
accounts are reported as parental investments in question 89, including
all accounts owned by the student and all accounts owned by the parents
for any member of the household.
Money received, or paid on your behalf, also includes distributions to
you (the student beneciary) 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). You must include these distribution
amounts in question 44i.
Investments do not include the home you live in, the value of life
insurance, ABLE accounts, retirement plans (401[k] plans, pension funds,
annuities, non-education IRAs, Keogh plans, etc.) or cash, savings and
checking accounts already reported in questions 40 and 88.
Investments also do not include UGMA and UTMA accounts for which
you are the custodian, but not the owner.
Investment value means the current balance or market value of these
investments as of today. Investment debt means only those debts that
are related to the investments.
Business and/or investment farm value includes the market value of
land, buildings, machinery, equipment, inventory, etc. Business and/or
investment farm debt means only those debts for which the business or
investment farm was used as collateral.
Business value does not include the value of a small business if your
family owns and controls more than 50 percent of the business and the
business has 100 or fewer full-time or full-time equivalent employees.
For small business value, your family includes (1) persons directly related
to you, such as a parent, sister or cousin, or (2) persons who are or were
related to you by marriage, such as a spouse, stepparent or sister-in-law.
Investment farm value does not include the value of a family farm that
you (your spouse and/or your parents) live on and operate.
Notes for question 48 (page 5)
Answer “Yes if you are currently serving in the U.S. Armed Forces or are
a National Guard or Reserves enlistee who is on active duty for other than
state or training purposes.
Answer “No” if you are a National Guard or Reserves enlistee who is on
active duty for state or training purposes.
Notes for question 49 (page 5)
Answer “Yes” (you are a veteran) if you (1) have engaged in active duty
(including basic training) in the U.S. Armed Forces, or are a National
Guard or Reserves enlistee who was called to active duty for other than
state or training purposes, or were a cadet or midshipman at one of the
service academies, and (2) were released under a condition other than
dishonorable. Also answer “Yes” if you are not a veteran now but will be
one by June 30, 2022.
Answer “No” (you are not a veteran) if you (1) have never engaged in
active duty (including basic training) in the U.S. Armed Forces, (2)
are currently an ROTC student or a cadet or midshipman at a service
academy, (3) are a National Guard or Reserves enlistee activated only for
state or training purposes, or (4) were engaged in active duty in the U.S.
Armed Forces but released under dishonorable conditions.
Also answer “No” if you are currently serving in the U.S. Armed Forces
and will continue to serve through June 30, 2022.
Notes for question 52 (page 5)
Answer “Yes” if at any time since you turned age 13:
• You had no living parent, even if you are now adopted; or
• You were in foster care, even if you are no longer in foster care today;
or
• You were a dependent or ward of the court, even if you are no longer
a dependent or ward of the court today. For federal student aid
purposes, someone who is incarcerated is not considered a ward of
the court.
If you are not sure if you were in foster care, check with your state
child welfare agency. You can nd that agencys contact information at
childwelfare.gov/nfcad.
The nancial aid administrator at your school may require you to provide
proof that you were in foster care or a dependent or ward of the court.
Notes for questions 53 and 54 (page 5)
The denition of legal guardianship does not include your parents, even
if they were appointed by a court to be your guardians. You are also not
considered a legal guardian of yourself.
Answer “Yes” if you can provide a copy of a court’s decision that as of today
you are an emancipated minor or are in legal guardianship. Also answer
Yes” if you can provide a copy of a court’s decision that you were an
emancipated minor or were in legal guardianship immediately before you
reached the age of being an adult in your state. The court must be located
in your state of legal residence at the time the court’s decision was issued.
Answer “No” if you are still a minor and the court decision is no longer in
eect or the court decision was not in eect at the time you became an
adult. Also answer “No” and contact your school if custody was awarded
by the courts and the court papers say custody” (not guardianship”).
The nancial aid administrator at your college may require you to provide
proof that you were an emancipated minor or in legal guardianship.
Notes for questions 55–57 (page 5)
Answer “Yes” if you received a determination at any time on or after
July 1, 2020, that you were an unaccompanied youth who was homeless
or at risk of being homeless.
• Homeless” means lacking xed, regular and adequate housing. You
may be homeless if you are living in shelters, parks, motels, hotels,
public spaces, camping grounds, cars, abandoned buildings, or
temporarily living with other people because you have nowhere else
to go. Also, if you are living in any of these situations and eeing an
abusive parent, you may be considered homeless even if your parent
would otherwise provide a place to live.
• Unaccompanied” means you are not living in the physical custody
of your parent or guardian.
Answer “No” if you are not homeless or at risk of being homeless, or
do not have a determination. However, even if you answer No” to
each of questions 55, 56, and 57, you should contact the nancial
aid administrator at the college you plan to attend if you are either
(1) homeless and unaccompanied or (2) at risk of being homeless,
unaccompanied, and providing for your own living expenses - as your
college nancial aid oce can determine that you are “homeless” and are
not required to provide parental information.
The nancial aid administrator at your college may require you to
provide a copy of the determination if you answered “Yes” to any of
these questions.
Notes for students unable to provide parental information on
pages 6 and 7
Under very limited circumstances (for example, your parents are
incarcerated; you have left home due to an abusive family environment;
or you do not know where your parents are and are unable to contact
them), you may be able to submit your FAFSA form without parental
information. If you are unable to provide parental information, skip
Steps Four and Five, and go to Step Six. Once you submit your FAFSA
form without parental data, you must follow up with the nancial aid
oce at the college you plan to attend, in order to complete your
FAFSA form.
Notes for Step Four, questions 58–92 (pages 6 and 7)
Review all instructions below to determine who is considered a parent
on this form:
• If your parent was never married and does not live with your other
legal parent, or if your parent is widowed and not remarried, answer
the questions about that parent.
• If your legal parents (biological, adoptive, or as determined by the
state [for example, if the parent is listed on the birth certicate]) are not
married to each other and live together, select “Unmarried and both
legal parents living together” and provide information about both of
them regardless of their gender. Do not include any person who is
not married to your parent and who is not a legal or biological parent.
Contact 1-800-433-3243 for assistance in completing questions
79-92, or visit
StudentAid.gov/fafsa-parent.
• If your legal parents are married, select “Married or remarried.” If your
legal parents are divorced but living together, select “Unmarried and
both legal parents living together.” If your legal parents are separated
but living together, select “Married or remarried,” not “Divorced or
separated.”
• If your parents are divorced or separated, answer the questions about
the parent you lived with more during the past 12 months. (If you did
not live with one parent more than the other, give answers about
the parent who provided more nancial support during the past 12
months or during the most recent year that you actually received
support from a parent.) If this parent is remarried as of today,
answer the questions about that parent and your stepparent.
• If your widowed parent is remarried as of today, answer the questions
about that parent and your stepparent.
Notes for questions 83 (page 6)
and 100 (page 8)
In general, a person may be considered a dislocated worker if he or she:
• is receiving unemployment benets due to being laid o or losing a
job and is unlikely to return to a previous occupation;
• has been laid o or received a lay-o notice from a job;
• was self-employed but is now unemployed due to economic
conditions or natural disaster; or
• is the spouse of an active duty member of the Armed Forces and
has experienced a loss of employment because of relocating due to
permanent change in duty station; or
• is the spouse of an active duty member of the Armed Forces and
is unemployed or underemployed, and is experiencing diculty in
obtaining or upgrading employment; or
• is a displaced homemaker. A displaced homemaker is generally a
person who previously provided unpaid services to the family (e.g.,
a stay-at-home mom or dad), is no longer supported by the spouse,
is unemployed or underemployed, and is having trouble nding or
upgrading employment.
Except for the spouse of an active duty member of the Armed Forces, if
a person quits work, generally he or she is not considered a dislocated
worker even if, for example, the person is receiving unemployment
benets.
Answer “Yes” to question 83 if your parent is a dislocated worker. Answer
Yes” to question 100 if you or your spouse is a dislocated worker.
Answer “No” to question 83 if your parent is not a dislocated worker.
Answer “No” to question 100 if neither you nor your spouse is a dislocated
worker.
Answer “Dont know” to question 83 if you are not sure whether your
parent is a dislocated worker. Answer “Dont know” to question 100 if
you are not sure whether you or your spouse is a dislocated worker. You
can contact your nancial aid oce for assistance in answering these
questions.
The nancial aid administrator at your college may require you to
provide proof that your parent is a dislocated worker, if you answered
Yes” to question 83, or that you or your spouse is a dislocated worker, if
you answered “Yes” to question 100.