Vous êtes sur la page 1sur 5

2011-2012 UCI Dependent Student Electronic Verification Signature

Office of Financial Aid and Scholarships 102 Aldrich Hall Irvine, CA 92697-2825 (949) 824-8262 www.ofas.uci.edu (949) 824-4876 (fax)

*73392716EVSIGN,,11*
SIU, JANET LEE - 73392716 U C

You MUST print, sign and submit this form with the following documentation: a SIGNED copy of pages one and two of parent(s)' federal tax return with Schedule E, if applicable. (Only page one required for 1040EZ.) We do not accept IRS electronic signatures.
By signing this worksheet, we certify that all the information reported to qualify for federal student aid is complete and correct. We also certify that we understand that the Office of Financial aid may request additional information to verify information reported on this form.

SIU, JANET LEE


Student's Name (print): Last First Middle

X
Signature Date

X
Parent's Name (print): Last First Middle Signature Date Household Size & Family Members in College Relationship to the student Born on or after January 1, 1988? For family members born on or after January 1, 1988 who will enroll at least 1/2 time in College in 2011-2012 Name of College

Full Name

Y N N N N

Degree pursuing

SIU, JANET LEE Karen Siu Annie Siu Trinh Ly Donald Siu

Self Sister/Stepsister Sister/Stepsister Mother/Stepmother Father/Stepfather

Yes Yes Yes No No

UC Irvine

BS, BA

Household member not claimed on parent's taxes or Relationship listed as 'Other':

Explanation of 'Other' degree type:

Explanation of Other Untaxed Income (if applicable):

Confirmation #59328-8416

Page 1 of 5

12/15/2011 12:31:28PM

SIU, JANET LEE - 73392716 U C

Supplemental Information/Programs
Yes No No Yes No No

Dislocated Worker Supplemental Security Income Food Stamps Free or Reduced Price School Lunch Temporary Assistance for Needy Families (TANF) Special Supplemental Nutrition Program for Women, Infants & Children (WIC)

Parent(s)' 2010 tax and income information


No

Parent(s) filed or will file a 1040A or 1040EZ: Attach a complete signed copy Parent(s) filed or will file a 1040: Attach a signed copy of pages one and two of the parent's tax return. If required to file a Schedule E, you must attach this schedule. Parent(s) filed or will file a Puerto Rican or other foreign tax return: Attach a signed, translated, notarized copy. Convert all figures to U.S. dollars. Parent(s) earned income in 2010 but will not file and is/are not required to file a 2010 federal tax return.

Yes

No

No

Father's total earned in 2010 ( attach W-2 forms) Mother's total earned in 2010 ( attach W-2 forms)

No

Parent(s) did not earn any income in 2010 and did not file an income tax return.

Student(s)' 2010 tax and income information


No

Student filed or will file a 1040A or 1040EZ: Attach a complete signed copy Student filed or will file a 1040: Attach a signed copy of pages one and two of the student's tax return. If required to file a Schedule E, you must attach this schedule. Student filed or will file a Puerto Rican or other foreign tax return: Attach a signed, translated, notarized copy. Convert all figures to U.S. dollars. Student earned income in 2010 but will not file and is/are not required to file a 2010 federal tax return.

No

No

No

Student's total earned in 2010 ( attach W-2 forms)

Yes

Student did not earn any income in 2010 and did not file an income tax return.

Confirmation #59328-8416

Page 2 of 5

12/15/2011 12:31:28PM

SIU, JANET LEE - 73392716 U C

2010 Additional Financial Information


Child support paid because of divorce or separation (attach supporting documentation). Do not include foster care or adoption payments. Taxable earnings from Federal Work-Study or other need-based work programs (attach W-2 forms). Combat pay or special combat pay included in your IRS 1040 adjusted gross income. Note: Do not enter untaxed combat pay. (Please attach W-2 forms.) Earnings from work under a cooperative education program offered by a college.

Parent

Student

Total from 01/01/2010 to 12/31/2010

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

2010 Untaxed Income


Payments to tax-deferred pension and savings plans (paid directly or withheld from earnings), include amounts reported on the W-2 Form in Box 12a-12d codes D, E, F, G, H, and S. Child support received for all children. Do not include foster or adoption payments. Housing, food and other living allowances paid to members of the military, clergy and others (including cash payments and cash value of benefits). Don't include the value of on-base military housing or the value of a basic military allowance for housing. Veteran non-educational benefits, such as Disability, Death Pension, or Dependency & Indemnity Compensation (DIC) and/or VA Educational Work-Study allowances. Do not include social security benefits. Other untaxed income such as workers compensation, disability, etc. Do not include Social Security benefits, Supplemental Security Income, on-base military housing or housing allowance; or combat pay. (explain): Money received, or paid on your behalf (e.g., bills) not reported elsewhere on this form.

Parent

Student

Total from 01/01/2010 to 12/31/2010

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

$0.00

xxxxxxxxx

$0.00

Confirmation #59328-8416

Page 3 of 5

12/15/2011 12:31:28PM

SIU, JANET LEE - 73392716 U C

Asset Information
Parent(s) Total cash, savings and checking account balances Investments
Real Estate Investments Purchase Date Purchase Price

$30,000 $1,000
Unpaid Mortgage Market Value

Partnerships

Market Value

Debt

Full Time Employees

Controlling Interest

Real Estate

Share Percentage

Partnerships

Explanation of partnership debt is greater than the values

Business and/or Investment Farm

Market Value

Debt

Full Time Employees

Controlling Interest

Real Estate

Business and/or Investment Farm

Explanation of business value is less than the unpaid business debt

Confirmation #59328-8416

Page 4 of 5

12/15/2011 12:31:28PM

SIU, JANET LEE - 73392716 U C S Corporation


Market Value

Debt

Full Time Employees

Controlling Interest

Real Estate

Share Percentage

S Corporation

Explanation of partnership debt is greater than the values

Confirmation #59328-8416

Page 5 of 5

12/15/2011 12:31:28PM