uc santa cruz
FINANCIAL AID AND SCHOLARSHIP OFFICE
UCSC Student’s ID /Account
Number (Do not use CRUZ ID)
13TAXDSPKT
Click to Print
First Name
UCSC Student’s Last Name
2012–2013 Tax Extension Packet for Dependent Student
You, the parent, have indicated that you have an extension to file your 2011 federal tax return. Please submit the IRS documents listed below. If the
student has also filed an extension, the student must also submit the IRS documents listed below. If the student does not file a federal tax return, check
this box q and complete the rest of this form. If the student did file a federal tax return for 2011, please attach the return with all schedules and
attachments and also complete the rest of the form.
Priority Due Date: June 15, 2012.
q 2010 Federal IRS Tax Return (Do not send your state return.) Be sure the return is signed.
Attach and sign copies of your 2010 1040, 1040A, or 1040EZ IRS federal tax return along with all schedules and attachments.
q 2011 W-2 and/or 1099 Forms
Include all W-2s and/or 1099 forms received from your employer(s) if applicable.
q Copy of IRS Extension
Provide a copy of the IRS form 4868 or a copy of the IRS’s extension approval for 2011.
q This Completed Form
Answer every question. DO NOT LEAVE BLANKS. If something does not apply to you, respond
using “N/A” (not applicable) or a “0” (zero). A blank answer will mean the information is incomplete and you will be asked to complete a new packet which may delay your eligibility for receiving financial aid.
Income INFORMATION
Income for the twelve (12) month period of January 1, 2011 through December 31, 2011.
Do Not Leave Blank
Wages earned from work by student $___________________
/yr.
Do Not Leave Blank
Wages earned from work by father or stepfather $___________________
/yr.
Wages earned from work by mother or stepmother $__________________/yr.
Do Not Leave Blank
q Check here if you received subsidized low-income housing such as HUD, Section 8, food stamps and/or TANF (do not include below).
TAXABLE INCOME
Parent(s)Student
Interest & dividend income
Do Not Leave Blank
$________________
$________________
Do Not Leave Blank
Alimony
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
Business income
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
Capital gains (or loss)
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
Other gains (or loss)
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
Retirement/pension benefits
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
Rental property, royalties,
partnerships, S corporation,
trust income
Do Not Leave Blank
$________________
$________________
Do Not Leave Blank
Farm income
Do Not Leave Blank
Do Not Leave Blank
$________________
$________________
Unemployment compensation
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
Taxed Social Security benefits
Do Not Leave Blank
$________________
$________________
Do Not Leave Blank
Paid lump sum benefits:
retirement, vacation,
sick pay, etc.
$________________
$________________
Do Not Leave Blank
Do Not Leave Blank
UNTAXED INCOME
Parent(s)
Student
Payments to tax-deferred pension
and savings plan (e.g. 401K)
$________________
Do Not Leave Blank $_________________
Do Not Leave Blank
IRA, Keogh, SEP, SIMPLE retirement
contributions
$ ________________$_________________
Do Not Leave Blank
Do Not Leave Blank
Child support received
Do Not Leave Blank $_________________
Do Not Leave Blank
$________________
Tax exempt interest
$________________
Do Not Leave Blank $_________________
Do Not Leave Blank
Untaxed IRAs/pension
distributions excluding rollovers
$________________
Do Not Leave Blank $_________________
Do Not Leave Blank
Housing, food and other living allowances paid to members of the military, clergy and others
(including cash payments and cash value of benefits). Do not include the value of on-base
military housing or the value of a basic military allowance for housing.
$________________
Do Not Leave Blank $_________________
Do Not Leave Blank
Veterans noneducation benefits
$________________
Do Not Leave Blank $_________________
Do Not Leave Blank
Other untaxed income not reported such as workers’ compensation, disability, etc. Do not
include student aid, earned income credit, additional child tax credit, welfare payments,
untaxed Social Security benefits, Supplemental Security Income, Workforce Investment Act
educational benefits, on-base military housing or a military housing allowance, combat pay
(if you are not tax filers), benefits from flexible spending arrangements (e.g., cafeteria plans),
foreign income exclusion or credit for federal tax on special fuels.
$________________
Do Not Leave Blank $_________________
Do Not Leave Blank
Page 1 of 3
complete ALL pages of this PACKET
F3EXT
UCSC Student’s ID /Account
Number (Do not use CRUZ ID)
First Name
UCSC Student’s Last Name
Savings, Investments and Other Assets on the Date the FAFSA was Filed
Note: Investments do not include the home you live in, the value of life insurance, retirement plans (pension funds, annuities,
non-education IRA’s, Keogh plans, etc.)
ParentStudent
Cash, Savings and Checking Accounts
Do Not Leave Blank
$____________________
Do Not Leave Blank
$____________________
Trust Funds
Do Not Leave Blank
$____________________
Do Not Leave Blank
$____________________
UGMA/UTMA Accounts
Do Not Leave Blank
$____________________
Do Not Leave Blank
$____________________
Money Market
$____________________
Do Not Leave Blank
$____________________
Do Not Leave Blank
Mutual Funds
Do Not Leave Blank
$____________________
Do Not Leave Blank
$____________________
Certificates of Deposit
$____________________
Do Not Leave Blank
$____________________
Do Not Leave Blank
Do Not Leave Blank
Do Not Leave Blank
Stock$____________________
$____________________
Stock Options
Do Not Leave Blank
$____________________
Do Not Leave Blank
$____________________
Bonds, other securities
Do Not Leave Blank
$____________________
Do Not Leave Blank
$____________________
Installment and Land Sale Contracts
$____________________
Do Not Leave Blank
$____________________
Do Not Leave Blank
Other (specify)_____________________________ $____________________
Do Not Leave Blank
Do Not Leave Blank
$____________________
Educational Benefits
$____________________
Do Not Leave Blank
N/A
$____________________
Educational Savings Accounts
Do Not Leave Blank
$____________________
N/A
$____________________
529 College Savings Accounts for all family members
Do Not Leave Blank
$____________________
N/A
$____________________
Refund Value of 529 Prepaid Tuition Plans
Do Not Leave Blank
$____________________
N/A
$____________________
_______________________
______________________
For Office Use Only
Total Investments Parent Real Estate Investments
Does your parent own real estate investments excluding the home you live in?
q Yes
q No
If yes, provide details below.
Complete this information for all real estate you own other than the home you live in such as mobile homes, condos, duplexes,
rental property, land, summer homes, etc. as of the date the 2012-13 FAFSA was filed.
If you have additional properties, attach a separate sheet with required information.
Property 1 (Do not report the home you live in):
Current Market Value* $ ____________ Mortgage Balance $ ____________ Purchase Price $ ____________ Year Acquired _______
Property Address _______________________________________________________________________________________________
Street address
City
State
Zip Code
Complete this section if you, the parent, RENTED OUT A PORTION OF THE HOME YOU LIVE IN that meets the following criteria:
the rental unit has its own entry and includes a kitchen and bath. The portion of your home that generates rental income is
considered an asset and must be reported as an investment net worth on the FAFSA. Complete the following information about
the home you live in:
Current Market Value* $ ___________ Mortgage Balance $ ___________ Purchase Price $ ___________ Year Acquired ______
Rental Square Footage ___________ + Home Square Footage ___________ = Total Dwelling Square Footage ___________
*on the date you filed the FAFSA
For Office Use Only
Total Current Market Value _______________ – Total Mortgage Balance ________________ = Real Estate Net Worth_________________________
Total Investments_____________________ + Real Estate Net Worth ___________________ =Total Investment Net Worth_____________________
Page 2 of 3
You must complete all pages of this packetF3PTXD
UCSC Student’s ID /Account
Number (Do not use CRUZ ID)
First Name
UCSC Student’s Last Name
STUDENT REAL ESTATE INVESTMENTS
Does the student own any real estate investment property
q Yes
q No
Household Information
List the people in your household. Include yourself, your spouse, and your children, if (a) you provide more than half of their support or (b) the
children would be required to provide parental information when applying for Federal Student Aid. List any other people if they now live with
you and you provide more than half of their support and will continue to provide more than half of their support from July 1, 2012 through June
30, 2013. If you have additional people to list, attach a separate sheet of paper with the required information.
Full Name of Family
Member in Household
Age Relationship
Date
to Student
of Birth
MM/DD/YY
Social Security Number
Father/
Stepfather
–
–
Mother/
Stepmother
–
–
–
–
–
–
–
–
–
–
–
–
UCSC
Student
self
Other
Members in
Household
Name of College
(if attending in
2012–2013)
For those enrolled in
college for 2012–13,
list current degree
objective.*
UCSC
Student living arrangements during the 2012–13 academic year (check one):
q On Campus
q Off Campus
q With parents
q Undecided
CERTIFICATION
•
•
•
•
I hereby declare that all information reported on this document is true, complete, and accurate to the best of my knowledge.
I understand that any false statement or misrepresentation will be cause for denial, reduction, cancellation and/or repayment of financial aid.
I understand that verifications of enrollment will be required if family members are listed in college.
This document must be received no later than June 15, 2012 to meet the priority deadline for all types of financial aid.
Parent, please check your marital status as of the date you submitted the 2012-2013 Fafsa application. Please provide the month and year
you were married, separated, divorced, widowed, or a California Registered Domestic Partner in the box next to your selection.
Single
Divorced
Separated
MonthYear
MonthYear
Married/Remarried
Widowed
MonthYear
MonthYear
California Registered Domestic Partner
MonthYear
Parent Signature ___________________________________ Date_____/_____/________ Parent Name ___________________________________
please print
(
)
Parent Phone ___________________________________
Parent E-Mail Address _______________________________
Student Signature _________________________________________ Date_____/_____/________
Return to: UC Santa Cruz Financial Aid and Scholarship Office, 205 Hahn Student Services Building, 1156 High Street, Santa Cruz, CA 95064
Phone: (831) 459-2963 Web: financialaid.ucsc.edu. For your protection and security, please do not e-mail forms.
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You must complete all pages of this packetF3PTXD