Fillable Form 201: INDEPENDENT FOREIGN TAX CONVERSION FORM 9 (Grand Canyon University)

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Form 201: INDEPENDENT FOREIGN TAX CONVERSION FORM 9 (Grand Canyon University)

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CompletethefollowingfieldswiththeappropriateU.S.dollar
equivalencyforforeignincomeearnedbythestudentand
spouseasofthetimethisformissigned.
Attachasignedcopyof201
7foreignincometaxaccount informationandall2017foreignwagestatementsifapplicable.
A. Student/Spouse Information
STUDENTNAME:_______________________________________GCUSTUDENTNUMBER:_______________
CATEGORY STUDENT SPOUSE
FOREIGNVALUE U.S.EQUIVALENCY FOREIGNVALUE U.S.EQUIVALENCY
AdjustedGrossIncome(AGI)
IncomeEarnedfromWork
TaxesPaid
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spouse:
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certifiesthatalloftheinformationreportedistrueandcorrect
StudentSignature:______________________________________________________Date:_______________________
PAGE1OF1
INDEPENDENT FOREIGN TAX CONVERSION FORM
201
9 - 2020
P0509282018
If all of the income earned in 2017 was in a foreign country, conversion of all foreign income earned is required.
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Form 201: INDEPENDENT FOREIGN TAX CONVERSION FORM 9 (Grand Canyon University)

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Completed 16 August 2020

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