I FELICIAN [Ie 0 L LEG E

The Franciscan College of New Jersey2015-2016 SUPPLEMENTAL INFORMATION STATE OF NEW JERSEY HESAA Student Aid Programs

STEP 1 - STUDENT INFORMATION

Last Name First Name Social Security Number Student ID Number

Pennanent Address Street & Number CitylState!Zip Date ofBirth

Local Phone Number (Include Area Code) Pennanent Phone Number (Include Area Code) Email Address

STEP 2- Indicate the appropriate response in the box next to each item listed below:

Student/Spouse indicate yearly

amount

2014 Untaxed Income Parent(s) indicate yearly

amount

a. Earned Income Credit from IRS Form 1040 - line 64a or 1040A-line 38a.

b. Untaxed Social Security Benefits from IRS Form1 040 -line 20a minus 20b or 1040A-line 14a minus 14b or from your SSA 1099 statement.

c. Taxable Social Security Benefits from IRS Form 1040 - Line 20, or Form 1 040A - Line 14b

d. Unemployment Compensation from IRS Form 1040 - Line 19, IRS Form 1 040A ­ Line 13, or Form 1040EZ Line 3

Student OTHER INFORMATION Please complete -> c. Driver's License State and Number:

State__ #

Please complete -> d. Veterans Educational Benefits for 2015-16:

- Type of benefits ­-Amount Per Month - $

-Number of Months to be received during academic year ­

STEP 3 - CERTIFICATION: By signing this worksheet, I certify all the information reported is complete and correct:

Student Signature Date Student Name (Please Print) Student

Parent Signature (IF student;s dependent) I Spouse Signature (If student is married) Date Parent/Spouse Name (Please Print) Spouse Social Security Number

If your spouse does not have a Social Security Number but has a Taxpayer Identification Number (TIN), enter your spouse's TIN. If your spouse does not have a Social Security Number or a Tax Payer Identification Number, enter 000000000.

Return completed form and any other pertinent documents to: Felician College-Financial Aid Office

262 South Main Street Lodi, NJ 07644

OR FAX TO: 201-559-6025

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