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

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

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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
2021 - 2022
P0109082020
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
spouse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. St
udent/Spouse Information
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INDEPENDENT FOREIGN TAX CONVERSION FORM 2021 - 2022 (Grand Canyon University)

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Completed 28 January 2021

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