College Planning Service America STUDENT INFORMATION Family Data Profile (updated 07/04/2017) Last Name First Name Middle Initial Social Security Number Date Of Birth Male/Female Home Address (Include Apt. #) City State Zip Code State Of Legal Residence Were You A Legal Resident Before 01/01/2012? When Did You Become A Legal Resident? Home Phone Number Student Email Address Student Marital Status Student Driver s License Number Student Driver s License State -- // M F Yes No Month _ Year _ --
US Citizen If Not, Alien Registration Number Are You Registered With Selective Service? When You Begin College, What Will Your High School Completion Status Be? What Is The Name Of Your High School? What City & State Is Your High School Located? Yes No A Yes No (Register Me) High School Diploma When You Begin This Coming School Year, What Will Be Your Grade Level? Hs Sr Fr So Jr Sr When You Begin This Coming School Year, 1 st Bachelor s 2 nd Bachelor s What Degree Will You Be Working On? Master s Doctorate Associate s Certificate Are You Interested In Being Considered For Work Study? Will You Have Your First Bachelor s Degree Before 07/01/2016? Highest School Your Father Completed Highest School Your Mother Completed Drug Conviction Affecting Eligibility Yes No Yes No Hs College Post Grad Hs College Post Grad Yes No
SCHOOL SELECTION SUMMARY Name Of School Location Housing (On/Off Campus, Commuter) Notes Regarding College Choices:
PARENT INFORMATION Current Marital Status Single Married Divorced/Separated Widowed Date Of Marriage // Date Of Divorce/Separation // Date Widowed // Father s Social Security Number -- Mother s Social Security Number -- Father s Last Name Mother s Last Name Father s First Name Mother s First Name Father s Middle Initial Mother s Maiden Name Father s Date Of Birth // Mother s Date Of Birth // Father s Driver s License Number Mother s Driver s License Number Father s Driver s License State Mother s Driver s License State Father s State Of Legal Residence Mother s State Of Legal Residence Did Father Become A Legal Resident Before Did Mother Become A Legal Resident Before 01/01/2012? Yes No 01/01/2012? Yes No When Did Father Become Legal Resident? / When Did Mother Become Legal Resident? / *Father s Email Address *Mother's Email Address * Check Box For Email To Be Used For All Official Correspondence
Family Member Relation To Date of Birth School Year/Grade Student Self X Parent X Parent X Brother/Sister Brother/Sister Brother/Sister Total In Household: Total In College:
PARENTS FINANCIAL INFORMATION What Type Of Return Does Family File? What Was Family s Adjusted Gross Income For 2017? Line 37 (1040) / Line 21 (1040A) / Line 4 (1040EZ) 1040 1040a 1040ez How Much Did Father Earn From Working (Salary/Wages/Tips)? (From W-2, 1099 Or Lines 7, 12, 18 From 1040) How Much Did Mother Earn From Working (Salary/Wages/Tips)? (From W-2, 1099 Or Lines 7, 12, 18 From 1040) Is Either Parent Currently Unemployed (Dislocated Worker)? Yes No Did The Family Receive Benefits From Any Of The Federal Programs Listed Below? Supplemental Security Income (SSI) Food Stamps Or SNAP Free Or Reduced Price Lunch Temporary Assistance For Needy Families WIC None Of The Above If Family Filed A 1040 Federal Form, Were They Eligible To File A 1040a Or 1040ez? Enter The Amount Of Federal Income Tax Paid (Line 56) Enter The Total Number Of Family Exemptions Yes No
ADDITIONAL PARENTAL FINANCIAL INFORMATION Education Credits (American Opportunity, Hope, Lifetime Learning) (Line 50) Child Support Paid Taxable Earnings From Need-Based Employment Programs Student Grant & Scholarship Aid Reported In The Family AGI Combat Or Special Combat Pay Earnings From Work Under Co-Op Program Through College UNTAXED INCOME Payments To Tax-Deferred Pension, And Savings Plans Boxes 12a-12d-Codes D, E, F, G, H, S) (W-2, IRA Deductions And Payments To Self-Employed SEP, Keogh 28 + 32) (Lines Child Support Received For All Children Tax Exempt Interest Income (Line 8b) Untaxed IRA Distributions (EXCLUDE ROLLOVERS)(Line 15a-15b) Untaxed Portion Of Pensions (EXCLUDE ROLLOVERS)(Line 16a-16b) Living Allowances Paid To Military Or Clergy Or Others Veteran s Non-Education Benefits (Disability, Death Pension) Other Untaxed Income (Workmen s Compensation, Disability)
PARENTAL ASSESTS Financial Institution Type Of Account Account Value _ Checking _ Checking _ Savings _ Savings _ Money Market _ Mutual Funds _ Mutual Funds/Stocks _ Mutual Funds/Bonds _ 529/TAP _ Real Estate (Other Than Primary Residence) TOTAL
STUDENT FINANCIAL INFORMATION What Type Of Return Does Student File? 1040 1040a 1040ez Non-Filer What Was Student s Adjusted Gross Income For 2017? Line 37 (1040) / Line 21 (1040A) / Line 4 (1040EZ) How Much Did Student Earn From Working (Salary/Wages/Tips)? (From W-2) Did The Student Receive Benefits From Any Of The Federal Programs Listed Below? Supplemental Security Income (SSI) Food Stamps Or SNAP Free Or Reduced Price Lunch Temporary Assistance For Needy Families WIC None Of The Above If Family Filed A 1040 Federal Form, Were They Eligible To File A 1040a Or 1040ez? Enter The Amount Of Federal Income Tax Paid (Line 56) Enter The Total Number Of Family Exemptions Yes No
STUDENT ASSETS Financial Institution Type Of Account Account Value _ Checking _ Savings _ Money Market _ Mutual Funds _ Mutual Funds/UTMA ADDITIONAL INFORMATION Father s Occupation Number Of Years Name of Employer Address Of Employer Work Phone -- Cell Phone -- TOTAL Mother s Occupation Number Of Years Name of Employer Address Of Employer Work Phone -- Cell Phone --
BUSINESS INFORMATION Name Of Business Business Address City, State, Zip Owner Percentage Of Ownership % Date Business Started Type Of Business Federal Tax Form Filed // S-Corp C-Corp LLC Sole Proprietor K-1 Schedule C Approximate Value Of Business (Assets-Liabilities) REAL ESTATE PRIMARY RESIDENCE Year Purchased Purchase Price Estimated Value FHIM Value Mortgage: Lender Term 10 15 20 30 Years Remaining Balance Monthly Payment (Include Insurance & Taxes) If You Do Not Have A Motgage On Primary Residence, List The Amount Of Monthly Rent Paid
OTHER REAL ESTATE Location Year Purchased Purchase Price Estimated Value FHIM Value Mortgage: Lender Term 10 15 20 30 Years Remaining Balance Monthly Payment (Include Insurance & Taxes) OTHER REAL ESTATE Location Year Purchased Purchase Price Estimated Value FHIM Value Mortgage: Lender Term 10 15 20 30 Years Remaining Balance Monthly Payment (Include Insurance & Taxes)
INSURANCE & RETIREMENT Name Of Insured Insurance Company Type Amount WL T UL WL T UL WL T UL Owner Location WL T UL Amount Type IRA/SEP/403b 401k-active/inactive Savings/Pension Needs Analysis & Recommendations: