EFTA01222457.pdf

Student Information Worksheet 2017 • Keep for your records Name of Student Social Security Number Part I — Student Status 1 Was this person a student during 2017? =Yes = No 2 What kind of school did the student attend during 2017? (Check all that appl a Elementary cI I College (postsecondary) e Military academy b High school (secondary) d Vocational school Not a liable cable . 3 Did the student receive scholarships or other education assistance? In No Part II — College Student Information 1 Did the student complete the first 4 years of postsecondary education as of 1/1/2017? =Nes Inn" In NA 2 Was this student enrolled at an eligible education institution during 20179 =Yes =No n NA 3 Was this student enrolled in a program that leads to a degree, certificate, or credential? lilies =No n NA 4 Was this student taking courses as part of a postsecondary degree program or to acquire or improve job skills? inYeS In No In NA 5 Did this student take at least one-half the normal full-time workload for one academic period'' inYeS in No In NA 6 Has this student been convicted of a felony for possessing or distributing _ 7 a controlled substance? Is this student an eligible dependent of the taxpayer? Fives (Yes No NA NA I No 8 In how many prior years has an American Opportunity Credit been claimed for this student? . . . 9 In how many prior years has a Hope Credit been claimed for this student Part Ill — Education Credit and Deduction Qualifications (Determined based entries in Part II) 1 Is this student qualified for the American Opportunity Credit? Fives F- 1 No 2 Is this student qualified for the Lifetime Learning Credit? ni feS n No 3 Is this student qualified for the Tuition and Fees Deduction? El ves n No Part IV — Educational Institution and Tuition Summary Received 2016 10981 with Box 2 filled and box 7 checked? —9 Address Tuition Scholar- On School Name (number, street, apt no., paid ships Form EIN city, state, and ZIP Code) or grants 1098-T Ye Ye- No No If a foreign address: foreign province/state: Postal code: Country: Yet _I Yes_ I I Non No If a foreign address: foreign province/state: Postal code: Country: Totals Are all School Employer Identifification Numbers (EIN) known? (School EIN's must be entered in the program to claim the American Opportunity Credit) eves In No EFTA01222457  Page 2 Part V — Education Assistance (Scholarships, Fellowships, Grants, etc.) Total Taxable Tax-free 1 Educational assistance that is always tax-free: a Veteran or employer assistance from Form 1098-1 Worksheets . b Other veteran assistance or certain Indian tribal payments c Other tax-free employer-provided assistance d Total 2 Scholarships, fellowships, and grants not reported on Form W-2: a Scholarships and grants from Pail IV above b Other scholarships, fellowships and grants c Total 3 Scholarship reported in 2017 not allocable to 2017 expense . . . 4 Amount required to be used for other than qualified education expenses 5 Subtract line 3 and 4 from line 2c 6 Total qualified education expenses from Part VI below 7 If student is a candidate for a degree, enter the amount used for qualified education expenses, otherwise, enter -0-. 8 Subtract line 7 from line 5 9 Taxable part. Add lines 4 and 8 10 Tax-free educational assistance. Add lines ld and 7 Part VI — Education Expenses Description Total Amount eligible for American Lifetime Tuition Qualified Qualified Qualified Qualified Oppor- Learning and Fees Higher Higher Higher Elementary tunity Credit Deduct- Education Education Education and Credit ion Expense Expense Expense Secondary for for for Expense 529 Plan ESA US Bonds for ESA Expenses: 1 Tuition paid from Part IV - Paid to institution as a condition of enrollment: 2 Fees 3 Books. supplies, equipment Paid to other than institution or not a condition of enrollment: 4 Books. supplies. equipment li 5 Other courserelated . . 6 Room and board 7 Special needs expenses . 8 Computer expenses . . . ■ 9 OTP or ESA contribution 10 Academic tutoring 11 Uniforms 12 Transportation ■ 13 Total qualified expenses - Adjustments: 14 Refunds 15 Tax-free assistance . . . 16 Deducted on Schad A . • • 17 Used for credit or deduction 18 Used for exclusion See tax help 19 Total adjustments 20 Adjusted qualified expenses EFTA01222458  Page 3 Part VII — Education Credit or Deduction Election 1 Elect credit or deduction which results in best tax outcome. 2 Elect the American Opportunity Credit 3 Elect the Lifetime Learning Credit 4 Elect the tuition and fees deduction 5 Not applicable Part VIII — Qualified Tuition Program (Section 529 Plan) For Purposes For Purposes of of 10% Regular Additional Tax Tax 1 Total Qualified Tuition Plan (QTP) distributions from Form 1099-O 2 Adjusted Qualified Higher Education Expenses 3 Qualified Higher Education Expenses applied to QTP distributions 4 Excess distributions. Subtract line 3 from line 1 If line 4 is greater than zero. complete lines 5 through 8. 5 Total distributed earnings from Form 1099-O box 2 6 Fraction. Divide line 3 by line 1. 7 Multiply line 5 by line 6 8 Earnings taxable to recipient. Subtract line 7 from line 5. Part IX — Education Savings Account (ESA) For Purposes For Purposes of of 10% Regular Additional Tax Tax 1 Total Education Savings Account (ESA) distributions from Form 1099-Q. . 2 Qualified Elementary and Secondary Education Expenses 3 Qualified Elementary and Secondary Education Expenses applied 4 Subtract line 3 from line 1. 5 Adjusted Qualified Higher Education Expenses 6 Qualified Higher Education Expenses applied to ESA distributions 7 Excess distributions. Subtract line 6 from line 4 8 Distributions taxable to recipient Part X — Series EE and I U.S. Savings Bonds Issued After 1989 1 Total proceeds from U.S. Savings Bonds cashed during 2017 for this student 2 Adjusted Qualified Higher Education Expenses 3 Qualified Higher Education Expenses applied to exclusion of U.S. bond interest 4 Interest included in line 1 5 Name and address of eligible educational institution(s) attended: Institution Name Institution Name Street address Street address City State Zip Code City State Zip Code EFTA01222459