Midlands Technical College-EOC-Parental IVF

PARENTAL INCOME VERIFICATION FORM

The Educational Opportunity Center (EOC) is a federally funded TRiO program and is required by the U.S. Department of Education to obtain income information for participants. It is important that you complete the form below or provide a copy of your tax return (1040) for the current year. If you are currently married (including legal same sex marriages) income information for both you and your spouse is required. All financial information will be kept confidential and will only be used for federal reporting purposes.
Parent Name*

First NameLast Name
Parent Email*
example@example.com
Parent Phone Number*
(999)999-9999
Parent Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Student Name*

First NameLast Name
Relationship to the Student*

Parent Income Information (if you filed a tax return)

Adjusted gross income (AGI) includes the amount of money earned in a year from working, wages, and tips. Use the box on the back of this form to locate your AGI on your tax return.

Taxable income is the amount of income the federal government
will actually tax. Use the box on the back of this form to locate your taxable income on your tax return.

You are considered a dislocated worker if you have been laid off
from a job, are currently receiving unemployment benefits, or are a displaced homemaker.

The household size is the number of people for whom the parent provides more than 50 percent of their support for the entire award year (see award year below for clarification). This may include people who live in the home, children who live outside the home, and unborn children who will receive more than half of the parents’ support during the award year.

An award year begins July 1 of the first year and ends June 30 of the second year.

Federal Tax Return	2019	2020
Taxable Income	1040 Line - 11b	1040 Line - 15
Adjusted Gross Income	1040 Line - 8b	1040 Line - 11
W2	Box 1	Box 1

Which tax year did you file an IRS income tax return for?*
As of today what is your marital status?*
What is your and or your spouse adjusted gross income?*
Refer to the table above to locate this information
What is your and or your spouse taxable income $ *
Refer to the table above to locate this information
As of today, is either parent currently a dislocated (unemployed) worker?*
How many people are in your household?*
Household size is the number of people for whom the parent provides more than 50% of their support for the entire award year (July 1 - June 30)
How many will be in college during the award year (not including parents)? *

Certification and Signatures
Please select all that apply*

I/Wecertify that all the information provided including my taxable income and/or annual gross income is correct and true to the best of my knowledge.I/We understand that the information provided on this application will be held in confidence by the EOC staff.I/We authorize the release of my school and/or financial records to the EOC program, including test scores and any other academic information and test results necessary to complete the programs application process.
Participant's Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy
Parent Signature*

Clear
Date*

MonthDayYear
mm-dd-yyyy