Supplemental Financial Data Form
T
his form is needed only if applicant’s parents/applicant’s spouse cannot submit data jointly on the electronic application.
If applicable, this form is to be uploaded along with the other supporting documents prior to application submission.
A. STUDENT INFORMATION
Last name First name Application ID#
Program Name
Permanent mailing address
City State/Province ZIP/Postal code Country
B. FAMILY FINANCIAL INFORMATION
The applicant’s parent/guardian(s) or Spouse (if applicable) must complete the following section.
1. State/Providence of Residence ……….………. 6. Medical and Dental Expenses not paid
by insurance (exclude premiums) ..………………...$
2. Adjusted Gross Income (FORM 1040) ……… $
7. Total Cash, Checking, Savings, and Cash Value of
3. Total Federal Tax Paid (FORM 1040) ………. $ Stocks (exclude retirement plan funds, IRA, 401k) $
(Not the amount withheld from paychecks)
8.
T
otal number of family members living in the household
4. Total Income of Parent/Spouse.……………… $ and primarily supported by the reported income …#
Total Income of Stepparent (if applicable)…. $ 9. Marital status of parent or guardian (if applicable):
Married Divorced Separated Widowed Single
5. (U.S. Only) Yearly Untaxed Income and Benefits:
Please indicate source – 10. Of the total number of family members on line 8, number of
Social Security Child Support students attending college at least half-time during the next
Other ____________________
….……… $ school year (include applicant, exclude parents) …#
C. CERTIFICATION AND SIGNATURES
Applicant’s Signature
Parent’s/Spouses Signature
D
o you have legal custody of applicant? Yes No
Is applicant your dependent? Yes No
Date Completed
Certification: All information provided is complete and
accurate to the best of my (our) knowledge. If
requested, I (we) will provide proof of information
including a copy of my (our) most recently filed income
tax return. Falsification of information or refusal to
provide information may result in rejection of this
application or termination of any award granted.
