STUDENT NAME:_____________________________ ID #:____________________ BIRTH DATE: _______________
Page 4
DEPENDENT AND INDEPENDENT STUDENT INFORMATION.
Education Tax Credits $______________
Receive federal means-tested benefits within the past 2 years (Supplemental Security Income Program {SSI}, Food Stamp
Program, Free or Reduced Priced School Lunch Program, Temporary Assistance to Needy Families, Special Supplemental Nutrition Program for
Women, Infants, & Children {WIC})
Yes No
Dislocated Worker
Yes No
Allowances
U.S Income Taxes Paid $_____________ $__________
Child Support PAID $_____________ $__________
Student Financial Aid $_____________ $__________
Include Earnings form Federal Work Study or other need-based programs; Earnings from work under a cooperative Education Program (co-
op) offered by a college; Grand and Scholarship aid in excess of tuition, fees, and books, that was included in AGI; AmeriCorps awards –
allowances & benefits
Assets
Cash, Savings & Checking $______________ $___________
Other Real Estate & Investment Equity (but NOT the student’s home)$______________ $___________
Business Equity $______________ $___________
Do you have more than 100 full-time employees?
Yes No
Farm Equity $______________ $___________
If you own a farm, report the calculated equity (value minus debt). To determine the value of land, buildings, machinery, equipment, livestock,
inventories, etc. Don't include the home if it is part of the farm. To determine the debt, include only the current pay-off amount of the mortgage
and related debts for which the farm was used as collateral. If you are not the sole owner(s), enter only your share of the equity.
Do you live on the farm?
Yes No
LOAN INFORMATION
Have you, the student, ever had any student loans?
Yes No
SIGNATURES
By signing this worksheet, I/we certify that all the information reported on this form is complete and correct. Our
signature(s) below authorize the process of determining eligibility for the Workforce Education Grant. I/we also
understand that this form is NOT to determine eligibility of federal financial aid.
Warning: if you purposely give false or misleading information on this worksheet, you may be fined, be
sentenced to jail, or both.
_________________________________________ __________________________________________
Student’s Signature (required) Date Parent’s Signature (required if Dependent) Date
Parent’s Info if Dependent
Student’s Info if Independent
Student’s Info if Dependent
Spouses Info if Independent