2021 Verification of Additional Financial Information

Please complete each answer for you and your parents (if dependent) or spouse (if married) as applicable.

Student Name Student Name First Last
Simmons ID
Student Email
CHILD SUPPORT PAID

Enter below, the total child support paid in 2021 (because of divorce/separation or as a result of legal requirements)
Student (& spouse if applicable)
Parent
Taxable Earnings from Need Based Employment (Federal Workstudy)

Enter below, the amount earned in 2021 from Federal Workstudy
Student (& spouse if applicable)
Parent
Taxable Grants/Scholarship Aid reported to the IRS as Income

Enter below, ONLY the amount of Grants/Scholarships that were taxable and reported on your IRS 1040 form
Student (& spouse if applicable)
Parent
Combat or Special Combat Pay

Enter below, ONLY the amount of combat pay that was included in your 2021 adjusted gross income on your tax return
Student (& spouse if applicable)
Parent
Earnings from Work Under a Cooperative Education Program Offered by a College

Enter below, ONLY the amount of earnings from a formal co-op placement in a College program.
Student (& spouse if applicable)
Parent
Certification and Signature

I certify that all of the information reported on this worksheet is complete and accurate.
(The student must sign this worksheet)
Draw your signature into the box below.

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.