Fillable DEPENDENT FOREIGN TAX CONVERSION FORM 2021 - 2022 (Grand Canyon University)

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DEPENDENT FOREIGN TAX CONVERSION FORM 2021 - 2022 (Grand Canyon University)

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If all of the income earned in 2019 was in a foreign country, conversion of all foreign income earned is required.
CompletethefollowingfieldswiththeappropriateU.S.dollarequivalencyforforeignincomeearnedbythestudentand
parent(s)asofthetimethisformissigned.
Attachasignedcopyof2019foreignincometaxaccount informationandall2019foreignwagestatementsifapplicable.
A. S
tudent/Parent(s) Information
STUDENTNAME:_______________________________________GCUSTUDENTNUMBER:_______________
CATEGORY STUDENT PARENT1 PARENT2
FOREIGN
VALUE
U.S.
EQUIVALENCY
FOREIGN
VALUE
U.S.
EQUIVALENCY
FOREIGN
VALUE
U.S.
EQUIVALENCY
AdjustedGross
Income(AGI)
IncomeEarned
fromWork
TaxesPaid
FilingStatus
Note:Under“U.S.Equivalency”ofthe“FilingStatus”lineinthegridabove,pleasenoteoneofthefollowingforeachof
thestudentandparent(s):
Single MarriedFilingJointly
HeadofHousehold MarriedFilingSeparately
QualifyingWidow/WidowerWithDependentChild
B. Certification and Signature (Handwritten Signature Required – Typed/Electronic Signature Not Accepted)
Bysigningbelowthestudentand parent(s) certifiesthatalloftheinformationreportedistrueandcorrect
StudentSignature:______________________________________________________Date:_______________________
ParentSignature:_______________________________________________________Date:_______________________
PAGE1OF1
DEPENDENT FOREIGN TAX CONVERSION FORM
2021 - 2022
P0109082020
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DEPENDENT FOREIGN TAX CONVERSION FORM 2021 - 2022 (Grand Canyon University)

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Completed 28 January 2021

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