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 Scholar- ships or grants 7 checked? On Form 1098-T —9 No No l If a foreign address: foreign province/state: ■ Postal code: Country: 1 NoNitIf 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 Oppor- tunity Credit Lifetime Learning Credit Tuition and Fees Deduct- ion 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