EFTA01220841

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 aH 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? =Yes =No NA 2 Was this student enrolled at an eligible education institution during 2014? =Ives =No 0 NA 3 Was this student enrolled in a program that leads to a degree, 4 certificate, or credential? Was this student taking courses as pan of a postsecondary degree =Yes 0 No 0 NA program or to acquire or improve job skills? =Yes 0No NA 5 Did this student take at least one-half the normal full-time workload for 6 one academic period? Has this student been convicted of a felony for possessing or distributing Oves Ow 0 NA 7 8 a controlled substance? Is this student an eligible dependent of the taxpayer? H H H Yes Yes In how many prior years has an American Opportunity Credit been claimed for this student? No No NA NA 9 In how many prior years has a Hope Credit been claimed for this student Part III — Education Credit and Deduction Qualifications (Determined based entries in Part II) 1 Is this student qualified for the American Opportunity Credit? =Yes n No 2 Is this student qualified for the Lifetime Learning Credit? QYes n No 3 Is this student qualified for the Tuition and Fees Deduction? nYeS n No Part IV — Educational Institution and Tuition Summary Received 2013 10987 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 ■ No lNo If a foreign address: foreign province/state: Postal code: Country: If a foreign address: foreign province/state: Postal code: Country: 1 NitNo 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 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 Pan 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 5 Other course-related . . 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 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 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 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