Student Information Worksheet 2014 • Keep for your records Name of Student Social Security Number Part I — Student Status 1 Was this person a student during 2014? nYes n No 2 What kind of school did the student attend during 2014? (Check all that appl a H Elementary cH College (postsecondary) e Military academy b High school (secondary) d Vocational school f Not applicable 3 Did he student receive scholarships or other education assistance? Li Yes l= No Part II — College Student Information 1 Did the student complete the first 4 years of postsecondary education as of 1/1/2014? 2 Was this student enrolled at an eligible education institution during 2014? 3 Was this student enrolled in a program that leads to a degree, certificate, or credential? 4 Was this student taking courses as pan of a postsecondary degree program or to acquire or improve job skills? 5 Did this student take at least one-half the normal full-time workload for one academic period? 6 Has this student been convicted of a felony for possessing or distributing a controlled substance? Yes 7 Is this student an eligible dependent of the taxpayer? Yes 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 =Yes =No =Ives =No 0 =Yes 0 No 0 =Yes 0No Oves Ow 0 H H No No H NA NA NA NA NA NA NA Part III — Education Credit and Deduction Qualifications (Determined based entries in Part II) 1 2 3 Is this student qualified for the American Opportunity Credit? =Yes QYes nYeS n No n No n No Is this student qualified for the Lifetime Learning Credit? Is this student qualified for the Tuition and Fees Deduction? Part IV — Educational Institution and Tuition Summary School Name EIN Received 2013 10987 Address (number, street, apt no., city, state, and ZIP Code) with Box 2 filled Tuition paid and box Scholarships or grants 7 checked? On Form 1098-T —9 No No l If a foreign address: foreign province/state: ■ Postal code: Country: 1 Nit No If a foreign address: foreign province/state: Postal code: Country: Totals EFTA01220841 Page 2 Part V — Education Assistance (Scholarships, Fellowships, Grants, etc.) Total Taxable Tax-tree 1 Educational assistance that is always tax-free: a Veteran or employer assistance from Form 1098-T Worksheets . b Other veteran assistance 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 Part IV above b Other scholarships, fellowships and grants c Total 3 Scholarship reported in 2014 not allocable to 2014 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 1d and 7 Part VI — Education Expenses Description Total Amount eligible for American Opportunity Credit Lifetime Learning Credit Tuition and Fees Deduction Qualified Higher Education Expense for 529 Plan Qualified Higher Education Expense for ESA Qualified Higher Education Expense for US Bonds Qualified Elementary and Secondary Expense for ESA 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 Expenses: Tuition paid from Pan IV . Paid to institution as a condition of enrollment: Fees Books. supplies. equipment Paid to other than institution or not a condition of enrollment: Books. supplies. equipment Other course-related . . Room and board Special needs expenses . Computer expenses . . . OTP or ESA contribution Academic tutoring Uniforms Transportation Total qualified expenses . Adjustments: Refunds Tax-free assistance . . . Deducted on Schad A . . Used for credit or deduction Used for exclusion See tax help Total adjustments. Adjusted qualified expenses EFTA01220842 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 of Regular Tax For Purposes of 10% Additional 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 of Regular Tax For Purposes of 10% Additional 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 2014 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 EFTA01220843