Student Financial Services University of Pennsylvania 005 Franklin Building 3451 Walnut Street Philadelphia, PA 19104-6270 www.sfs.upenn.edu Noncustodial Parent Information U.S. Citizens and Permanent Residents Academic Year 2018-2019 a copy of your most recent federal tax return and W2 forms are also required SectIoN a - StudeNt INformatIoN Last First Initial Birthdate Penn I.D. or Email Fax Social Security Number Student is: Applying for admission to Penn currently enrolled Students primary residence is with: Mother Father Equally with Mother and Father SectIoN B - NoNcuStodIal PareNt INformatIoN 1. Relationship to student Mother Father 2. Last First Initial Birthdate 3. Home Address Street City State Zip Code Phone # 4. Preferred Daytime Phone # Email 5. Indicate if you are self-employed employed unemployed 6. Occupation Employer 7. Number of years with current employer If unemployed, the date unemployment began SectIoN c - HouSeHold INformatIoN 8. What is your current marital status? single remarried separated divorced widowed 9. If you have remarried, complete the following information: a. the date of your marriage spouse s name b your spouse's occupation employer c. If unemployed, date unemployment began d. will your spouse be attending college at least one term during the 2018-2019 academic year? no yes If yes, the name of the school 1/6
10 List the people in your family. Include yourself, your spouse if you are married, the student, and other children under age 24 whom you share with the student's custodial parent even if they do not live with you. Include anyone else who lives with you and receives more than half of his or her support from you and your current spouse a. of Present of Institution Type of Institution b. of Present of Institution Type of Institution c. of Present of Institution Type of Institution d. of Present of Institution Type of Institution e. of Present of Institution Type of Institution f. of Present of Institution Type of Institution g. of Present of Institution Type of Institution 2/6
11. What is the total number in your household as listed in question #10? 12. Of the number in question #11, how many will be college students enrolled at least half time between July 1, 2018 and June 30, 2019? Do not include yourself or your spouse. Include the student. SectIoN d - financial SuPPort of former HouSeHold 13. Who will claim the student as a dependent on the 2016 income tax return? mother father neither parent 14. Annual child support paid for all children in 2017 Estimated for 2018 15. Annual child support paid for the student in 2017 Estimated for 2018 16. According to court order, when will (did) the student's child support end? 17. Annual alimony paid in 2017 Estimated for 2018 18. How much did you contribute toward the student's education, excluding child support, in the academic year? 19. How much do you plan to contribute toward the student's education in? 20. Is there an agreement specifying this contribution for the student's education? yes no SectIoN e - expenses 21. Total annual child support you and your spouse paid or will pay in 2017 Estimated for 2018 22. Repayment of your and your current spouse's educational loans in 2017 Estimated for 2018 23. Uninsured medical and dental expenses in 2017 Estimated for 2018 24. Total elementary, junior high and high school tuition paid for dependent children (do not include Penn student s tuition) 2017 Estimated for 2018 SectIoN f - NoNcuStodIal PareNt'S (and SPouSe'S, If remarried) INcome and BeNefItS 25. Indicate 2016 Taxable and/or Non-Taxable Income received from: a. Number of exemptions claimed ( 2016 IRS forms 1040 and 1040A, line 6d) b. Wages, salaries, tips ( 2016 IRS forms 1040 and 1040A, line 7 or 1040EZ, line 1) c. Interest income (2016 IRS forms 1040 and 1040A, line 8a or 1040EZ, line 2, or Telefile, line C) d. Dividend income (2016 IRS forms 1040 and 1040A, line 9a) e. Net income or loss from business, farm, rents, royalties, partnerships, estates trusts, etc* (2016 IRS form 1040, lines 12, 17, and 18) To enter a loss, use a minus (-) sign. f. Other taxable income, such as alimony received, capital gains (or losses) pensions, annuities, etc (2016 IRS form 1040, lines 10,11,13,14,15b,16b,19, 20b, and 21; 1040A, lines 10, 11b, 12b, 13, and 14B or 1040EZ line 3, or Telefile, line D) g. Adjustments to income (2016 IRS form 1040, line 36, or 1040A, line 20) h. Adjusted gross income (2016 IRS form 1040, line 37 or 1040A, line 21, or 1040EZ, line 4 or Telefile, line 1) 3/6
Section f Noncustodial Parent's (and spouse's, if remarried) Income and Benefits (continued) Refer to 2016 Tax Return for approximate line references. 2016 (Estimate if 2015 tax return is not yet completed) 26. Itemized Deductions (2016 IRS Schedule A, line 29) 27. Number of Exemptions 28. Education Credits Hope and Lifetime Learning (2014 IRS form 1040, line 50 or 1040A, line 31) 29. U.S. income tax paid in 2016 (2016 IRS form 1040, line 55 or 1040A, line 36 or 1040EZ, line 10 or Telefile, line K(2) 30. a. Income you earned from work b. Income your spouse earned from work 31. Untaxed Income and Benefits (Annual Amount) a. Untaxed portion of social security benefits received for all family members except the student b. Social Security benefits for the student c. Welfare benefits, including TANF d. Child support received for all children e. Payments to tax-deferred pension and savings plans f. Earned Income Credit (2016 IRS form 1040, line 64A or 1041A, line 41, or 1040EZ, line 8 or Telefile, line L) g. Housing, food and other living allowances received by military, clergy, and others h. Tax-exempt interest income (2016 IRS form 1040 or 1041A, lines 8b) i. Other untaxed income SectIoN g - 2017 INcome and BeNefItS 32. Adjusted Gross Income (2016 IRS Form 1040, line 37;Form 1040A, line 21;Form 1040EZ, line 4;Telefile,line I) 33. U.S. income tax paid (2016 Form 1040, line 55; 1040A, line 36;1040EZ, line 10;Telefile, line K ) 34. Itemized deductions (2016 IRS Schedule A, line 29) 35. Untaxed income and benefits * If the answer is a dollar amount (+ or -), include a copy of your most recent federal income tax return, all pages, schedules and W2 forms. 4/6
SectIoN H - estimated 2018 INcome and BeNefItS 36. a. Income you will earn from work b. Income your spouse will earn from work 37. Other taxable income 38. Untaxed income and benefits SectIoN I - NoNcuStodIal PareNt S (and SPouSe S If married) assets 39. Total cash, checking and savings accounts as of today 40. a. Total value of assets held in the names of your and your spouse s children who are under 19 and not college students. Do not include the student b. Total value of assets held in Section 529 prepaid tuition plans for you and your spouse s children. Do not include the student. c. Total value of assets held in Section 529 prepaid tuition plan for the student 41. Investments Total value of stocks, bonds, savings bonds, mutual funds, C.D.s, money market funds, and all other investments except real estate 42. Primary Home (If you rent, check here and skip to 42e) a. What is it worth today? b. Current amount owed c. Year purchased d. Purchase price e. Monthly mortgage or rent payment 43. Real Estate other than your Primary Home a. What is it worth today? b. Current amount owed c. Year purchased d. Purchase price 44. Do you or your spouse own all or part of a business or farm? no yes, a business yes, a farm a. What is it worth today? b. What is owed on it? 5/6
SectIoN J - SPecIal circumstances and explanations Use this space to explain any unusual expenses such as high medical or dental expense, educational and other debts, child care, elder care, or special circumstances in your family. Attach additional pages if necessary. We hereby certify that the information presented on this application is correct at this time. Signature of noncustodial parent date 6/6
HoW to SuBmIt Your completed form 1) Submit forms to Student financial Services by 1 of these 3 methods - do not send duplicate forms. 2) always complete and submit a tax I.d. coversheet whenever you submit a forms to SfS. Submit electronically (Preferred method) 1) You must have access to Adobe Acrobat Reader 10 or higher and a scanner. 2) Download the Form and Tax I.D. Coversheet to your computer by selecting File > Save As. 3) DO NOT edit the Application in your browser. 4) Launch Adobe Acrobat Reader from your computer and open the saved Form through Acrobat by selecting File > Open. 5) Complete the Form and Tax I.D. Coversheet by typing your answers into the fields, saving frequently. TIP: Test that the document is saved correctly after compleing one field before continuting. 6) Print the completed Form and Coversheet out and sign with ink. 7) Scan the complepted Form and Coversheet with signatures into your computer and save as a.pdf or.jpeg. 6) Submit the completed and signed Form and Tax I.D. Coversheet to: https://www.sfs.upenn.edu/forms/onlinedocsubmitform.php Paper / fax 1) Print out and complete the Form and Tax I.D. Coversheet. 2) Fax completed and signed Form and Tax I.D. Coversheet to 215-573-5428 (Be sure to fax both sides of 2-sided documents). Paper / mail 1) Print out and complete the Form and Tax I.D. Coversheet 2) Mail the completed and signed Form and Tax I.D. Coversheet to this address: Student Financial Services University of Pennsylvania 005 Franklin Building 3451 Walnut Street Philadelphia, PA 19104-6270 7