Student Aid Form - St. James School

OFFICE USE ONLY
Barcode
St. James School
Rockford, IL
School Code: 1585 (SCHL)
PSAS: 0725 P-R-N-B (PK-8)
2014
2015
PARENT NAME
Student Aid Form
_3_003_SCHL_1585
This form must be postmarked no later than july 1, 2014.
TO COMPLETE THIS APPLICATION YOU WILL NEED TO INCLUDE:
1. Detailed copies of all pages and Schedules of your 2013 Federal Income Tax Return Form
1040, 1040A, or 1040EZ (as filed with the IRS) for individuals listed in Sections A and B.
Recaps and/or Summary Forms are not acceptable. If you file Schedule(s) A, C, E, F or a
statement of dependence, you must provide copies. If you have not yet filed, or are not required
to file a tax return, see the REQUIRED DOCUMENTATION section of the INSTRUCTIONS.
2. Copies of all 2013 W-2 Wage and Tax Statement Forms, all 2013 1099/1099R for Interest/
Dividends, Pensions/Annuities and/or Misc. Income Forms for individuals listed in Sections A
and B (Please make sure all documentation is copied on regular 81/2 x 11 paper - documentation
cannot be returned).
3. Documentation of TOTAL AMOUNTS received in 2013 for all Non-Taxable Income (see
Section G for specific requirements).
4. Check or Money Order payable to PRIVATE SCHOOL AID SERVICE for the non-refundable
application fee of $27.00 (All returned checks will incur an additional fee of $25.00).
5. This application form filled out in its entirety, signed and dated by the individuals listed in
Sections A and B.
IMPORTANT: If the above items do not accompany this application,
your application will not be considered complete.
Keep a copy of this completed application and all documentation for your records.
Form #003 (2013)
To check the processing status of your application, go to www.psas.org.
STUDENT
NAME
Please note: This application requires documentation for income received in 2013.
Print Form Clear Form
Save Form
S tudent A id F o r m
Form #003 (2013)
//
2014 -2015
IMPORTANT: Print clearly and neatly with a blue or black ball point pen
A
B
Parent, Guardian, or Other Adult
Responsible for Tuition
Check One:
m Father m
m Step-Father m Step-Mother m Other Adult
Mother
Last Name
First Name
M.I.
Social Security Number
Parent, Guardian, or Other Adult
Residing with Parent A
Check One:
m Father m
Mother
Last Name
First Name
M.I.
(
) (Area Code) Home Phone
Social Security Number
Age
m Step-Father m Step-Mother m Other Adult
Address
Apartment # (if applicable)
City
State
Zip Code
Age
(
) (Area Code) Home Phone
Address
Apartment # (if applicable)
City
State
Zip Code
(
(
) (
) ) (
) (Area Code) Work Phone
(Area Code) Cell Phone
(Area Code) Work Phone
(Area Code) Cell Phone
Employed by
How Long? E-mail Address
Employed by
How Long? E-mail Address
Preferred Contact #:
m Home m Work m Cell or m E-mail
m If you are self-employed, please check
May PSAS contact you at work if there are questions? m Yes m No C
and refer to Section K of this form.
Preferred Contact #:
m Home m Work m Cell or m E-mail
m If you are self-employed, please check
May PSAS contact you at work if there are questions? m Yes m No and refer to Section K of this form.
Dependents (DO NOT LEAVE BLANK)
Number of dependent children who will attend a tuition charging school: daycare, Pre-K, elementary school, secondary school, or college in the fall of 2014? Please list all dependent children in order of oldest to youngest, including college students, even if you are not applying for aid for that student. Indicate each dependent’s relation
to Parent/Guardian A: child, foster child, grandchild, etc.
Dependent
Last Name
Dependent
First Name
M.I.
Date
of
Birth
Relation
to Parent/
Guardian A
Name, city, and state of school student
plans to attend in the Fall of 2014.
DO NOT ABBREVIATE
Grade in
the fall
of 2014
School Name
1
School Name
School Name
School Name
m m
City and State
School Name
5
Office
Use Only
m m
City and State
4
No
Tuition
charged
yearly per
student?
m m
City and State
3
Yes
Amount I/We
feel I/We can
pay toward
tuition?
m m
City and State
2
Applying
for Aid?
m m
City and State
m Please check if additional dependents are listed on a separate sheet.
D
Household Information
1. Number of individuals who will reside in my/our household during the 2014-2015
school year:
Parents/Guardians
Children
Other*
*If Other, please explain
E
2. Current marital status/housing arrangement of Parent/Guardian A:
m a. Single, never Married* m d. Divorced* m g. Residing with Other
m e. Remarried* m h. Other:
m b. Married
m f. Separated*
m c. Widowed
*If Single, Divorced, Remarried, or Separated, you are required to complete Section E.
Single, Divorced, Remarried, or Separated Parents (To be completed by the Parent/Guardian listed in Section A)
1. Date of separation (Month/Year) 2. Date of divorce (Month/Year) 3. Non-custodial parent (Last, First, M.I.) 4. Who claimed student as a tax dependent in 2013? 5. Who is responsible for the tuition for the dependent(s) listed in Section C?
Child Support (per year)
Father Name:
Names of students
father is responsible for:
Percent of tuition
paid (per student):
Mother Name:
Names of students
mother is responsible for:
Percent of tuition
paid (per student):
Names of students
other is responsible for:
Percent of tuition
paid (per student):
Other Name:
*If the person(s) above is/are responsible for additional students, please list in Section L.
%
q Received
$
q Received
%
$
q Received
%
$
q Paid
$
q Paid
$
q Paid
$
q Neither
q Neither
q Neither
Form #003 (2013)
F
G
Taxable Income
The 2013 federal tax return for student’s household was:
m Filed
m Not filed yet (See Required Documentation section)
m I/We do not file. I/We only receive non-taxable income - Go to Section G
Actual 2013
1. Total number of exemptions claimed on Federal
Income Tax form.
Estimate 2014
$
$
3. Parent/Guardian B total taxable income from W-2
wages (Box 1). Total income for Parent B only
$
$
$
5. Other non-work taxable income from interest,
dividends, alimony, unemployment, and non business income. See 2013 1040 lines 8a, 9a-11, 13,
14, 15b, 16b, 19-21; See 2013 1040A lines 8a-14b
$
$
7. Total “Adjusted Gross Income” as reported on your
IRS 1040, 1040A, or 1040EZ.
See 2013 1040 line 37 or 1040A line 21
$
$
$
8. Total Tax Paid as reported on your IRS 1040,
1040A, or 1040EZ. See 2013 1040 line 61 or 1040A
line 35
$
$
9a.Medical/Dental expenses as reported on Schedule
A, line 1 of your IRS 1040 form.
$
$
9b.Charitable Contributions as reported on Schedule
A, line 19 of your IRS 1040 form.
$
m Rent m Own (go to line 22)
$
per month
b. Amount paid by other source(s)
$
per month
c. Are you current on your monthly payment?
$
per year*
a. Medicaid received in 2013?
m Yes
m No
m Yes
m No
a. What is the current market value?
b. What is the amount still owed, including
*
a. Total received in 2013
$
b. Total used for living expenses
$
per year*
15. Housing Assistance (Sec. 8, HUD, etc.)
$
per year*
a. Religious Housing Assistance
(parsonage, manse, etc.)
Total received in 2013
home equity loans?
c. What is the monthly mortgage payment?
d. Are you current on your monthly payment?
$
*
per year*
a. Any and all Military/VA Benefits and/or Compensation
Total received in 2013 (Identify source(s) in Section L)
$
per year*
17. Loans/Gifts from friends or relatives
$
per year
18. Personal Savings/Investment Accounts used for household
expenses (Do not include totals listed in Section I)
$
per year
19. Total non-taxable income for 2013
$
per year
Assets & Investments (Current Values)
23. Total amount in cash, checking, and savings accounts
$
stocks, bonds, CDs, or other securities
$
25. Total value of IRA, Keogh, 401K, SEP, or other
retirement accounts
a. What was your total contribution to your retirement
$
account(s) in 2013 (IRA, Keogh, 401K, SEP, etc.)?
$
26. If you own real estate other than your primary residence:
a. What is the fair market value?
$
b. What is the amount still owed?
$
27. Do you own a business?
m Yes
m No
$
a. What is the fair market value of your business?
$
$
b. What is the amount still owed?
$
$
per month
28. Do you own a farm?
m Yes
*
16. Other non-taxable income (Working for cash, Adoption and/
or Foster Subsidy, Worker’s Comp., Disability, Pension/
Retirement, etc. Identify source(s) in Section L)
$
22. If you own a residence:
$
If No, what was the total amount paid in 2013?$
m No
If No, what was the total amount paid in 2013?$
If Yes, please go to Section K.
m Yes
m No
If Yes, please go to Section K.
a. What is the fair market value of your farm?
$
b. What is the amount still owed?
$
Unusual Circumstances (Check all that apply to your situation within the past 12 months)
q
per year*
24. Total value of money market funds, mutual funds,
a. Amount paid by household
per year*
$
I
$
12. Food Stamps (SNAP)
$
$
J
11. Cash Assistance (TANF)
*You must provide 2013 YEAR-END documentation for items 11-16a; either a YEAR-END Statement
from the appropriate Public Agency, or documentation showing totals from 1/1/13-12/31/13.
21. If renting, what is the monthly rental payment?
per year
Housing Information (DO NOT LEAVE BLANK)
20. Do you rent or own your residence?
$
a. Social Security income (SSI Only)
Total received in 2013
(Provide documentation for all recipients in household.)
$
$
6. Allowable “Adjustments to Income” as reported on
your IRS 1040, 1040A, or 1040EZ.
See 2013 1040 line 36 or 1040A line 20
10. Child Support
14. Student loans and/or grants received for PARENT’s education
(Not college attending dependents or students listed in Section C.)
Net business income* from self-employment, farm,
rentals, and other businesses. (*Go to Section K)
(Attach Schedules C, E, and/or F from your IRS
1040) See 2013 1040 lines 12, 17, and 18
H
List the total amount received from 1/1/13-12/31/13 for all recipients in the household.
DO NOT list monthly amounts.
13. Social Security income (SSA/SSD, etc.)
(Provide documentation for all recipients in household.)
2. Parent/Guardian A total taxable income from W-2
wages (Box 1). Total income for Parent A only
4.
Non-Taxable Income
q
q
q
a. Loss of job
b. Recent separation/divorce
c. Change in family living status d. Change in work status
q
q
q
q
e. Bankruptcy
f.
College expenses
g. Income reduction
h. Illness or injury
q
q
q
q
i. Death in the family
j. Shared custody
k. High debt
q
q
q
m. Medical/Dental expenses
n. Shared tuition
o. Other (explain in Section L)
l. Child support reduction
Keep a copy of this completed application and all documentation for your records.
Go to next page
Parent/Guardian A:
Print Name
K
SS#:
Business Owners or Self-Employed Individuals (2013 Estimates)
If you have not filed your 2013 Tax Return, and are Self-Employed, own a business, rental
property, and/or a farm please provide an
estimate of your income
- DO NOT LEAVE BLANK
1. What is your total estimated GROSS business income?
Schedule C
Schedule F
$
$
2. What is your total NET business taxable income/loss? (DO NOT LEAVE BLANK)
$
$
$
3. If your business pays your home rent or mortgage, what is the annual total?
$
4. If your business pays for your personal automobile, what is the annual total?
$
5. If your business pays any portion of other personal expenses, list total amount and explain in Section L.
$
6. If you own rental property: What was the total amount of Rental Income received?
$
L
$
Schedule E
Explanations (Use this space to explain any answers which may need clarification.)
M Certification, Authorization, and Documentation Requirements
WHAT IS REQUIRED TO PROCESS THIS APPLICATION
(IF ANY OF THE FOLLOWING IS MISSING, YOUR APPLICATION WILL NOT BE CONSIDERED COMPLETE.)
1. This application form filled out in its entirety, SIGNED AND DATED BELOW by the Parent(s)/Guardian(s) listed in Sections A and B.
2. A check or money order made payable to PRIVATE SCHOOL AID SERVICE in the amount of $27.00. This is a non-refundable application fee.
3.
If you have filed a
2013 IRS Form 1040:
If you have not yet filed a
2013 IRS Form 1040:
A complete photocopy of your 2013
A complete photocopy of your most recent Form 1040, 1040A,
or 1040EZ (as filed with the IRS, with all Schedules). 2013
W-2 Forms, 2013 1099/1099R, or 1098 Forms for any wageearning adult residing with the applicant(s). If this application
is submitted after April 15, 2014, you must provide a copy
of the 2013 Extension for Filing Request, as approved by
the IRS and a copy of your last filed tax return.
Form 1040, 1040A, or 1040EZ (as filed
with the IRS, including all Schedules).
2013 W-2 Forms, 2013 1099/1099R,
or 1098 Forms for any wage-earning
adult residing with the applicant(s).
If you do not file an IRS
Form 1040 AND receive only
non-taxable income:
Photocopies of your 2013 YEAR-END Social Services
statement (TANF, etc.). Food Stamp documentation,
Housing Assistance documentation, Student Loans and/
or grant documentation for parent’s education, Social
Security income statements showing TOTAL AMOUNTS
received in 2013 for ALL members of the household.
qAn electronic recap of this written application is available for an additional $5 fee. You must have an email address listed in Section A in order to receive
the electronic recap. Please check this box and include an additional $5 with your processing fee if you would like to receive an electronic recap.
Checkout
SIGN HERE
qNon-Refundable Application Processing Fee ..............................
qElectronic Recap Fee (optional) ..................................................
*Please make checks payable to PSAS
$27.00
$5.00
Total
I/We declare that the information on this form is true, correct, and complete to the best of my/our knowledge. I/We authorize PRIVATE SCHOOL AID
SERVICE to return this form and all attachments only to the schools and agencies named in Section C under contract with PSAS.
Parent/Guardian A
Date
Parent/Guardian B
Date
This Student Aid Form (SAF), all attachments and an analysis of your SAF are sent only to the school(s) or agencies contracting with PSAS.
You will not receive results from PSAS. No other agency will see or receive any information about this application or its attachments.
Mail completed application and photocopies of all documentation to:
PRIVATE SCHOOL AID SERVICE, P.O. BOX 89434, CLEVELAND, OH 44101-6434
Questions? Call: (440) 892-4272
Copyright © 2013 Private School Aid Service
INTRODUCTION
PRIVATE SCHOOL AID SERVICE (PSAS) is under contract with the
school, school system, or organization from which you obtained this
application for tuition assistance. Our purpose is to provide a reasonable
assessment of the ability of each family to pay for the education of their
children at private and independent elementary and secondary schools.
Your Student Aid Form, all attachments, and an analysis of your SAF
are sent only to the school(s) or agencies contracting with PSAS. No
other agency will receive any information about this application or
its attachments.
PRIVATE SCHOOL AID SERVICE does not make any decisions about
recipients and amounts of financial aid awarded. Recipients and amounts
of aid are determined by the designated school or agency. YOU WILL
NOT RECEIVE RESULTS FROM PRIVATE SCHOOL AID SERVICE.
INSTRUCTIONS
A&B
Parent, Guardian or Other Adult
This form should be filled out by the parent, guardian or other adult
responsible for the tuition of the child or children attending a private or
independent school contracting with PSAS. If the parents/guardians are
divorced or separated, only the parent responsible for the tuition and any
other adult residing in the household should fill out the form. If tuition is
shared, each responsible party must complete a Student Aid Form (SAF)
if financial aid is needed.
Detach Here
Answer all questions for both parent(s), stepparent(s), or guardian(s)
responsible for tuition for the dependent(s) listed in Section C. Do not
leave any questions blank. If natural parents are divorced, separated
or single, answer all questions in Section E. If natural parents are
divorced/separated and remarried, list information for custodial parent
and new spouse. If either parent answers “self-employed,” and has not
filed a tax return, complete Section K. If you provide your email address
to PSAS, it will be used for application related communication only.
Your email address will also be provided to the organizations you list
in Section C as part of your application. Your email address will not be
shared with any other third party.
CALCULATIONS ARE BASED ON TOTAL HOUSEHOLD INCOME.
C
Student Information
List all dependent children residing in your household in order of oldest
to youngest. Indicate the relation to Parent/Guardian A listed in Section
A of the application (i.e. child, grandchild, foster child, stepchild, etc.). If
your dependents will be enrolled in any tuition charging school or agency
next fall (including daycare, preschool, elementary school, high school,
college, or trade school), list the name of the school, city and state where
the school is located. List the grade your child(ren) will enter next fall
(2014-2015); the amount you feel you can pay toward tuition per year, and
the amount of tuition charged per student per year.
If “No” is checked for a student listed in Section C, that student will not
be considered for tuition assistance. For all additional dependents, use
a separate sheet.
NOTE: The information regarding tuition charged per student assists
PSAS in making the most equitable analysis of your ability to pay for
private education. If you are unsure, please estimate.
D
Household Information
ITEM 1: Enter total number of individuals living in the household. Include
any college students claimed on the tax return. Do not include children
who have moved out of the home. Include all family members dependent
on and residing with the parent listed in Section A.
ITEM 2: Check the appropriate box indicating custodial parents’ marital
status. If parents are single, divorced, remarried, or separated, complete
Section E.
E
Single, Divorced, Remarried, or Separated Parents
If dependent(s) parents are divorced or separated, or do not reside in
the same household, the custodial parent must provide the information
requested in Section E about the non-custodial parent.
If the date of separation took place in the year 2013, PSAS will
require copies of any tax returns filed jointly or independently by
both parent(s)/guardian(s) for 2013. Be sure to estimate the income
in Section F for 2014.
ITEM 5: Indicate who is responsible for tuition and what percentage for
the dependents listed in Section C. List the total amount of child support
actually received by custodial parents listed in Sections A & B. List the
total amount received and the total amount paid for 2013.
F
Taxable Income
List all actual amounts for 2013 and estimated amounts for 2014.
ITEM 1: Enter the total number of exemptions you claimed on your 2013
IRS Form 1040, 1040A, or 1040EZ.
ITEM 2: Enter the total 2013 taxable income earned in wages, salaries
and tips for parent/guardian/other listed in SECTION A. Attach all copies
of 2013 W-2 forms and/or 2013 1099 forms from all employers.
ITEM 3: Enter the total 2013 taxable income earned in wages, salaries
and tips for parent/guardian/other listed in SECTION B. Attach all copies
of 2013 W-2 forms and/or 2013 1099 forms from all employers.
ITEM 4: Enter the total net income from business (attach Schedule C
or C-EZ), all rents, royalties, partnerships (attach Schedule E), and all
farm income or loss (attach Schedule F). If you have received income
from any of these sources and are estimating your income for 2013, you
must also fill out Section K of this application. (See 2013 1040 lines 12,
17, and 18, enter sum total.)
ITEM 5: Enter the total of all other taxable income from interest, dividend
income (attach Schedule B if over $400), taxable refunds, credits or
offsets of state and local income taxes, alimony received, capital gain or
loss (attach Schedule D). List all capital gain distributions not previously
reported, total IRA distributions (if rolled-over, explain in Section L),
pensions and annuities, unemployment compensation, taxable social
security benefits, and any other taxable income. Attach copies of
all Form 1099/1099R, and/or Form 1098 for Interest/Dividends,
Pensions/Annuities or other misc. income. Attach copies of Social
Security Income statements and Unemployment Compensation
documentation for year-end 2013. (See 2013 1040 lines 8a, 9a-11, 13,
14, 15b, 16b, 19-21, or 1040A lines 8a-14b, enter sum total.)
ITEM 6: Enter allowable adjustments to income, such as IRA payments,
self-employment tax, self-employed health insurance deduction, Keogh
retirement plan and self-employed SEP deductions, penalty on early
savings withdrawals, and alimony paid. Add together to arrive at your
total adjustments. DO NOT include your standard deduction or deduction
amounts for each family member. (See 2013 1040 line 36, or 1040A line
20.)
ITEM 7: Enter total adjusted gross income as reported on your IRS
Form 1040, 1040A or 1040EZ. Attach all pages of the applicable tax
form (1040, 1040A, 1040EZ) for documentation. (See 2013 1040 line
37, or 1040A line 21.)
ITEM 8: Enter the Total Tax paid (not withheld) as reported on your
IRS Form 1040, 1040A, or 1040EZ. (See 2013 1040 line 61, or 1040A
line 35.)
ITEM 9a: Enter the total of any medical and dental expenses as reported
on Schedule A, line 1 of your IRS Form 1040 (attach Schedule A).
ITEM 9b: Enter the total amount of Charitable Contributions as reported
on Schedule A, line 19 of your IRS Form 1040 (attach Schedule A).
Keep a copy of this completed application and all documentation for your records.
G
J
Non-Taxable Income
If you receive non-taxable income, you must list and provide documentation
of the TOTAL YEARLY AMOUNTS received in 2013 for all recipients in the
household for the following: Cash Assistance (TANF), Food Stamps, Social
Security income, Student loans and/or grants (received for PARENT’s education),
Housing assistance (Section 8, HUD, etc.), Worker’s Compensation, Disability or
Retirement.
ITEM 10: Child support: Report total amount received for 2013 for all children
in the household.
ITEM 11: Cash Assistance (TANF): Report total amount received for 2013.
ITEM 12: Food Stamps (SNAP): Report total amount received for 2013. Do not
combine with TANF or Medicaid.
ITEM 12a: Did you receive Medicaid in 2013?
ITEM 13: Social Security benefits: Report the total non-taxable (SSA/SSD, etc.)
amount received in 2013 for all recipients in household.
ITEM 13a: Social Security benefits: Report the total non-taxable (SSI ONLY)
amount received in 2013 for all recipients in household.
ITEM 14: Student loans and/or grants: Report the total amount received in
2013 for PARENT’S education. Do not list loans, grants or scholarships received
for dependents in Section C. Identify how much of this income was used for
household expenses in 2013.
ITEM 15: Housing assistance: Report the total amount received for 2013.
Identify in Section L all sources of Housing assistance (government assistance,
Section 8, HUD, family/friends or other sources), including monies received toward
rental/mortgage payments and/or utilities.
ITEM 15a: Religious Housing assistance: Report the total amount received
for 2013.
ITEM 16: Other non-taxable income: Report all additional non-taxable income
received in 2013 including: Working for cash, Deductible IRA or Keogh payments;
untaxed portions of pensions; tax exempt interest income; foreign income
exclusion; Workers’ Compensation; cash support or any money paid on your
behalf, including support from a non-custodial parent or any other person (do
not include court ordered support here); adoption and/or foster care subsidy, or
any other benefit or income not subject to taxation by any government (Refugee
Assistance, etc.). Identify source(s) in Section L.
ITEM 16a: Any and all Military/VA Benefits and/or Compensation: Provide
your Leave and Earnings Statement (if applicable) and report the total amount
received for 2013 of food and other living allowances paid to members of
the military, veterans non-education benefits (Death Pension, Dependency
and Indemnity Compensation, etc.), VA Educational Work-Study, etc. Identify
source(s) in Section L.
ITEM 17: Loans/Gifts received from friends or relatives:
amount received in 2013.
Report the total
ITEM 18: Personal Savings/Investment Accounts: Report the total amount
used in 2013 for household expenses.
ITEM 19: Total non-taxable income for 2013: Add together Items 10-18.
H
Housing Information
ITEMS 20 and 21: If you rent your home or apartment, list your monthly rental
or lease payment here, including amounts paid by household and other sources.
Unusual Circumstances
Check any and all items that apply to your situation. If your circumstances require
explanation beyond the scope of this application, please notify the school to which
you are applying and also include a letter of explanation with this application.
K
Business Income
Provide 2013 Business Income Estimates if you have not filed your 2013
Tax Return.
ITEM 1: List estimated total GROSS business income for 2013.
ITEM 2: List estimated total NET taxable business income/loss for 2013.
ITEM 3: List the total amount paid by business in 2013 for home rent or mortgage.
ITEM 4: List the total amount paid by business in 2013 for personal automobile.
ITEM 5: List the total amount of personal expenses paid by business in 2013 that
do not fall into one of the categories above.
ITEM 6: List total amount of estimated rental income received in 2013.
If providing income estimates for more than one business, corporation or farm
(Schedule C, Schedule E and/or Schedule F) please list information for each
business, corporation or farm separately. Use additional sheet or Section L, if
necessary.
L
Explanation
If any specific question requires clarification, write a brief explanation in this space.
If your circumstances require explanation beyond the scope of this application,
please notify the school to which you are applying.
M
Certification, Authorization, and Documentation
Requirements
You must sign the form in this section. Your signature authorizes PSAS to release
the form and attachments to the contracting schools indicated in Section C. By
signing the form, you also certify that the information submitted is correct. This
application CANNOT be processed without the appropriate signature(s) and the
appropriate documentation.
REQUIRED DOCUMENTATION
If you have filed your 2013 IRS Form 1040:
If you have filed your 2013 IRS Form 1040:
You must submit photocopies of all pages of your 2013 Federal Tax Return Form
1040, 1040A or 1040EZ (as filed with the IRS, with all Schedules, 2013 W-2
Forms, 2013 1099/1099R, or 1098 Forms for any wage-earning adult residing with
the applicant(s). Do not include your State tax return unless requested.
If you have not filed your 2013 IRS Form 1040:
ITEM 21c: Indicate whether you are current on your monthly rental payment and
if not, what the actual amount was that you paid in 2013.
You must submit photocopies of all 2013 W-2 Forms, 2013 1099/1099R, or 1098
ITEM 22a: Determine the present value of the family home and list it. Local real
estate agents should be able to help you if you are unsure.
of all pages of your most recent Federal Tax Return Form 1040, 1040A or 1040EZ
ITEM 22b: Check with your lending institution and enter the amount still owed,
including second mortgages.
April 15, 2014, you must provide a copy of the 2013 Extension for Filing
ITEM 22d: Indicate whether you are current on your monthly mortgage payment
and if not, what the actual amount was that you paid in 2013.
I
Assets and Investments
Forms for any wage-earning adult residing with the applicant(s), and photocopies
(as filed with the IRS, with all Schedules). If this application is submitted after
Request, as approved by the IRS.
If you are an Independent Contractor or self-employed and have not
filed your 2013 IRS form 1040:
You must complete Section K and submit photocopies of all pages of your most
ITEM 23: List total of current balances in cash, savings, and checking accounts.
Do not include IRAs or Keoghs.
recent Federal Tax Return Form 1040, 1040A or 1040EZ (as filed with the IRS,
ITEM 24: List total current market value of money market funds, mutual funds,
stocks, bonds, CDs or other securities.
wage-earning adult residing with the applicant(s). If this application is submitted
ITEM 25: List total current market value of all retirement funds, including IRA,
Keogh, 401K, and SEP plans or other retirement accounts. List total amount
contributed in 2013 for Item 25a.
ITEM 26: Answer Items 26a and 26b for any and all investment real estate (not
including the family’s primary residence), if applicable. Second homes, rental
properties, and land contracts should be included.
ITEM 27: If you own a business, check the Yes box and answer Items 27a
and 27b. If you have not filed your 2013 tax return, complete Section K of this
application.
ITEM 28: If you own a farm, check the Yes box and answer Items 28a and 28b.
If you have not filed your 2013 tax return, complete Section K of this application.
with all Schedules), 2013 W-2 Forms, 2013 1099/1099R, or 1098 Forms for any
after April 15, 2014, you must provide a copy of the 2013 Extension for Filing
Request, as approved by the IRS.
If you receive non-taxable income:
You must submit photocopies of your 2013 YEAR-END (01/01/13 - 12/31/13)
Cash Assistance documentation (TANF, etc.), Food Stamp documentation,
Housing Assistance documentation, Student loan and/or grant documentation (for
PARENT’s education), Social Security Income statements, showing the TOTAL
AMOUNT received in 2013 for ALL members of the household. If you list any total
for line 16, you must identify source(s) in Section L.
Along with your application, you must include:
Form
Copies of your 2013 Form 1040,
1040A, or 1040EZ (all pages)
1040
2011
13
(99)
Department of the Treasury—Internal Revenue Service
U.S. Individual Income Tax Return
For the year Jan. 1–Dec. 31, 2011, or other tax year beginning
OMB No. 1545-0074
, 2011, ending
Your first name and initial
Last name
If a joint return, spouse’s first name and initial
Last name
IRS Use Only—Do not write or staple in this space.
See separate instructions.
, 20
Your social security number
Spouse’s social security number
Apt. no.
Home address (number and street). If you have a P.O. box, see instructions.
▲
City, town or post office, state, and ZIP code. If you have a foreign address, also complete spaces below (see instructions).
Foreign country name
2
3
Check only one
box.
6a
b
Exemptions
c
4
Single
Married filing jointly (even if only one had income)
Presidential Election Campaign
Head of household (with qualifying person). (See instructions.) If
the qualifying person is a child but not your dependent, enter this
child’s name here. ▶
Married filing separately. Enter spouse’s SSN above
and full name here. ▶
5
(1) First name
.
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.
(2) Dependent’s
social security number
Last name
.
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.
}
(4) ✓ if child under age 17
qualifying for child tax credit
(see instructions)
(3) Dependent’s
relationship to you
Boxes checked
on 6a and 6b
No. of children
on 6c who:
• lived with you
• did not live with
you due to divorce
or separation
(see instructions)
If more than four
dependents, see
instructions and
check here ▶
d
7
8a
b
9a
Attach Form(s)
W-2 here. Also
attach Forms
W-2G and
1099-R if tax
was withheld.
Enclose, but do
not attach, any
payment. Also,
please use
Form 1040-V.
Adjusted
Gross
Income
Total number of exemptions claimed
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8b
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8a
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9a
Qualified dividends . . . . . . . . . . .
9b
Taxable refunds, credits, or offsets of state and local income taxes
Alimony received . . . . . . . . . . . . . . .
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10
11
12
13
14
Business income or (loss). Attach Schedule C or C-EZ . . . . . . . . .
Capital gain or (loss). Attach Schedule D if required. If not required, check here ▶
Other gains or (losses). Attach Form 4797 . . . . . . . . . . . . .
.
12
13
14
15a
16a
17
IRA distributions .
15a
b Taxable amount . . .
Pensions and annuities 16a
b Taxable amount . . .
Rental real estate, royalties, partnerships, S corporations, trusts, etc. Attach Schedule E
15b
16b
17
18
19
20a
Farm income or (loss). Attach Schedule F .
Unemployment compensation . . . .
Social security benefits 20a
18
19
20b
21
22
Other income. List type and amount
Combine the amounts in the far right column for lines 7 through 21. This is your total income
23
Educator expenses
24
Certain business expenses of reservists, performing artists, and
fee-basis government officials. Attach Form 2106 or 2106-EZ
25
Health savings account deduction. Attach Form 8889
.
24
25
26
27
28
Moving expenses. Attach Form 3903 . . . . . .
Deductible part of self-employment tax. Attach Schedule SE .
Self-employed SEP, SIMPLE, and qualified plans
. .
26
27
28
29
30
31a
Self-employed health insurance deduction
Penalty on early withdrawal of savings . .
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29
30
31a
32
33
34
Alimony paid b Recipient’s SSN ▶
IRA deduction . . . . . . .
Student loan interest deduction . .
Tuition and fees. Attach Form 8917 .
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.
32
33
34
35
36
37
Domestic production activities deduction. Attach Form 8903
35
Add lines 23 through 35 . . . . . . . . . . . . .
Subtract line 36 from line 22. This is your adjusted gross income
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b Taxable amount
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▶
Add numbers on
lines above ▶
7
10
11
b
If you did not
get a W-2,
see instructions.
.
Wages, salaries, tips, etc. Attach Form(s) W-2 .
Taxable interest. Attach Schedule B if required .
Tax-exempt interest. Do not include on line 8a .
Ordinary dividends. Attach Schedule B if required
21
22
23
.
Copies of all pages of your 2013 IRS Form
1040, 1040A, or 1040EZ including all
Schedules.
o
Copies of ALL W-2 and 1099 Forms for
individuals listed in Sections A and B (All
documentation
Dependents on 6c
not entered above
Income
o
Qualifying widow(er) with dependent child
Yourself. If someone can claim you as a dependent, do not check box 6a .
Spouse
.
Dependents:
Make sure the SSN(s) above
and on line 6c are correct.
Check here if you, or your spouse if filing
jointly, want $3 to go to this fund. Checking
a box below will not change your tax or
refund.
You
Spouse
Foreign postal code
Foreign province/county
1
Filing Status
Documentation Checklist
a Employee’s social security number
.
.
.
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.
▶
36
37
Cat. No. 11320B
Form
1040
o
A check or money order for $27.00 made
payable
SERVICE. (All returned checks will incur
an additional fee of $25.00).
o
Copies of all required non-taxable income
to
PRIVATE
SCHOOL
Copies of your 2013 1099 Forms
(where applicable)
VOID
CORRECTED
1
Rents
OMB No. 1545-0115
2 Federal income tax withheld
13
10
$
3 Social security wages
4 Social security tax withheld
2
5 Medicare wages and tips
6 Medicare tax withheld
$
7 Social security tips
8 Allocated tips
3
9
e Employee’s first name and initial
13
Statutory
employee
Retirement
plan
PAYER’S federal identification
number
RECIPIENT’S identification
number
C
o
d
e
14 Other
5
7
RECIPIENT’S name
C
o
d
e
C
o
d
e
9
Street address (including apt. no.)
C
o
d
e
City, state, and ZIP code
f Employee’s address and ZIP code
Employer’s state ID number
16 State wages, tips, etc.
17 State income tax
18 Local wages, tips, etc.
19 Local income tax
Form
Wage and Tax
Statement
Copy 1—For State, City, or Local Tax Department
2013
2011
6 Medical and health care payments
$
2nd TIN not. 13
15b Section 409A income
$
Form
$
16
8 Substitute payments in lieu of
dividends or interest
$
Payer made direct sales of 10 Crop insurance proceeds
$5,000 or more of consumer
products to a buyer
(recipient) for resale $
12
Excess golden parachute 14 Gross proceeds paid to
payments
an attorney
$
15a Section 409A deferrals
Department of the Treasury—Internal Revenue Service
Copy C
For Payer
$
Nonemployee compensation
11
20 Locality name
Account number (see instructions)
W-2
Fishing boat proceeds
$
12c
Miscellaneous
Income
1099-MISC
4 Federal income tax withheld
12b
12d
15 State
Form
Other income
$
12a
Third-party
sick pay
Royalties
$
10 Dependent care benefits
Suff. 11 Nonqualified plans
Last name
AID
Keep a copy of this completed application
and all documentation for your records.
PAYER’S name, street address, city, state, ZIP code, and telephone no.
1 Wages, tips, other compensation
d Control number
on
regular 81/2 x 11 paper).
(2011)
(2013)
OMB No. 1545-0008
c Employer’s name, address, and ZIP code
copied
Copies of your 2013 W-2 Forms
FROM ALL EMPLOYERS
22222
be
documentation.
For Disclosure, Privacy Act, and Paperwork Reduction Act Notice, see separate instructions.
b Employer identification number (EIN)
should
For Privacy Act
and Paperwork
Reduction Act
Notice, see the
2013
2010 General
Instructions for
Certain
Information
Returns.
$
State tax withheld
$
$
1099-MISC
If you do not have all of the documentation required:
17 State/Payer’s state no.
18 State income
$
$
Department of the Treasury - Internal Revenue Service
Contact the IRS for a transcript of your complete 1040, 1040A, or 1040EZ, and any Schedules, etc.
Contact your employer for a copy of your W-2. Contact the appropriate company for a copy of your 1099.
Avoiding the Most Common Errors
THE MOST COMMON ERROR THAT APPLICANTS MAKE IS SENDING THE APPLICATION INCOMPLETE.
IN ORDER FOR AN APPLICATION TO BE REVIEWED, IT MUST INCLUDE:
•
All pages of your 2013 IRS Form 1040, 1040A, or 1040EZ (Federal Income Tax Return). Do not send your state tax return, recap, or tax summary.
(If you have not yet filed your 2013 IRS Form 1040, or you do not file, please see the Required Documentation Section of the instructions.)
•
2013 W-2 and/or 1099 Forms for individual(s) listed in Sections A and B (Please make sure all documentation is copied on regular 81/2 x 11 paper).
•
Non-taxable income verification.
•
A check or money order for the non-refundable application fee of $27.00. All returned checks will be subject to an additional $25.00 fee.
9 Print clearly and neatly with a blue or black ball point pen.
9 Make a photocopy of your completed Student Aid Form and all supporting documentation for your records.
9 Do not staple anything to the Student Aid Form.
9 Submit the original application only.
9 Affix proper postage to the envelope (applications without sufficient postage will be returned by the post office).
9 Do not send any original documents. Originals cannot be returned.
PSAS CANNOT PROCESS YOUR APPLICATION IF YOU HAVE NOT INCLUDED
THE REQUIRED DOCUMENTATION AND APPLICATION FEE.
Other Common Errors
Parent, Guardian or Other Adult
List the parent, guardian or other adult responsible for tuition and any
other adult residing in the household. Complete each section in its
entirety, including age, social security number, and name of employer.
If you are self-employed, check the box and refer to Section K. If you
provide your email address to PSAS, it will be used for application
related communication only. Your email address will also be provided to
the organizations you list in Section C as part of your application. Your
email address will not be shared with any other third party.
C
Student Information
List all dependent children, including college students, in order of oldest
to youngest. If any dependents will attend a tuition charging school next
fall, fill in all columns for those children.
D
Household Information
This section should include the total number of parents, children and
other individuals residing in the household. Any household member
listed as “Other” should be identified, using Section L if necessary for
explanation.
E
Single, Divorced, Remarried, or Separated Parents
This section should be completed by the custodial parent with information
about the non-custodial parent.
F
Taxable Income
Answer Items 1–9b for BOTH 2013 and 2014. YOU MUST include
documentation of all income received by both parents/guardians residing
with the applicant(s). If you are divorced or separated and receive child
support, list the yearly amount in Section G, Item 10.
G
Non-Taxable Income
List the YEARLY amounts received for Items 10-19. Remember, do not
list monthly amounts.
H
Housing Information
If you rent your home, list your monthly rental payment, including any
payments made by sources other than the household. If you own your
home, answer Items 22a, b, c, and d.
I
Assets and Investments
Enter the totals for Items 23, 24, and 25 based on your investment,
savings, and/or checking statements. If you own rental or investment
property, answer Items 26a and 26b. You must include Schedule E from
your IRS Form 1040.
If you answered “Yes” to Items 27 or 28 and are estimating 2013 income,
complete Section K of the application. You must include Schedule C, E
and/or Schedule F from your IRS Form 1040.
J
Unusual Circumstances
Check any and all items that apply to your situation. If your circumstances
require explanation beyond the scope of this application, please notify
the school to which you are applying and also include a letter of
explanation with this application.
K
Business Income (if estimating 2013 income)
Answer each question that pertains to your estimated income.
L
Explanation
If you feel that any specific question requires clarification and/or an
explanation, write a brief summary in the space provided.
M
Certification, Authorization, and Documentation
Requirements
Confirm that you have attached ALL REQUIRED DOCUMENTATION
and that you have signed the application.
Detach Here
A&B