Non-Custodial Parent Information Worksheet: 2011-2012
Hofstra North Shore-LIJ School of Medicine
Office of Financial Aid
500 Hofstra University
Hempstead, NY 11549-5000
email: [email protected]
phone: 516.463.7523
fax: 516.463.7543
Students that are interested in applying for need-based scholarship and loan programs offered through the
Hofstra North Shore-LIJ School of Medicine should first fill out the Institutional Aid Application. In
order to qualify for institutional funding we require that both biological parents provide the Office of
Financial Aid with financial information. This form is for the acquisition of non-custodial parent
information. Please do not leave any questions blank – an entry of “0” or “NA” is acceptable.
Section I: STUDENT INFORMATION
Name: __________________________ _________________________ ___________________
Last
First
AMCAS ID: _____________
OR
Middle
Hofstra Univ. 700 #: _____________
Section II: NON-CUSTODIAL PARENT INFORMATION
Name: __________________________ _________________________ ___________________
Last
First
Middle
Address: _______________________________________________ _____________________________
Number and Street
_______
Town or City
_____________
State
Zip Code
Relationship to student: Mother 
____________________ _________________________
Phone Number
Email Address
Father 
Date of Birth: ____ / ____ / ______
mm
Highest education:
dd
yyyy
High school 
Some college 
College 
Graduate / Professional school 
Occupation: _______________________________________
Employer: ________________________________________
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Non-Custodial Parent’s Spouse (if not applicable, check here ):
Name: __________________________ _________________________ _____________________
Last
First
Middle
Date of Birth: ____ / ____ / ______
mm
dd
yyyy
Highest education: High school 
Some college 
College 
Graduate / Professional school 
Occupation: _________________________________________
Employer: __________________________________________
2010 Federal Tax Filing Information (non-custodial parent and spouse):
 My non-custodial parent (and spouse) have filed their taxes for 2010. Signed copies are enclosed.
 My non-custodial parent (and spouse) have NOT filed their taxes for 2010 but anticipate filing on:
____ / ____ / ____
mm
dd
yyyy
 My non-custodial parent (and spouse) will not file their taxes for 2010.
Section III: NON-CUSTODIAL PARENT’S HOUSEHOLD INFORMATION
Number in household: _____
Include:
•
Non-custodial parent and spouse.
•
Other children if more than half of their support will be provided between July 1, 2011 and June 30, 2012.
•
Other people that live in the household and more than half of their support will be provided between July 1,
2011 and June 30, 2012.
Number in household that will be college students between July 1, 2011 and June 30, 2012: _____
Section IV: NON-CUSTODIAL PARENT’S FINANCIAL INFORMATION
Does the non-custodial parent receive any of the following?
Unemployment  Disability  Social Security 
Did the non-custodial parent file a joint 2010 tax return? Yes 
No 
If the non-custodial parent (and spouse) have filed their 2010 tax return, which form did they file (or
anticipate filing):
1040 
1040A 
1040EZ 
If non-custodial parent and spouse filed separately, please make appropriate selections below:
Non-custodial parent: 1040 
1040A 
1040EZ 
Spouse: 1040 
1040A 
1040EZ 
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What was the Adjusted Goss Income for 2010? (IRS form 1040 – line 34; 1040A – line 21; or 1040EZ
line4). $ ____________
What was the income tax paid for 2010? (Income tax amount is on IRS Form 1040 – line 55; 1040A –
line 35; or 1040EZ – line 11). $ ____________
The following two questions are related to earnings: Answer the questions whether or not a tax return was filed. This
information may be on the W-2 forms, or on IRS Form 1040—lines 7 + 12 + 18 + Box 14 (Code A) of IRS Schedule K-1
(Form 1065); on 1040A—line 7; or on 1040EZ—line 1. If any individual earning item is negative, do not include that item
in your calculation.
What was the non-custodial parent’s income earned from work in 2010: $__________
What was the non-custodial parent’s spouse’s income earned from work in 2010: $__________
As of today, what is the non-custodial parent’s (and spouse’s) total current balance of cash, checking, and
savings accounts? $__________
As of today, what is the net worth of the non-custodial parent’s (and spouse’s) investments, including real
estate? Don’t include the home in which your non-custodial parent lives. Net worth means current value
minus debt. $__________
As of today, what is the net worth of the non-custodial parent’s current businesses and/or investment
farms? Don’t include a family farm or family business with 100 or fewer full-time or full-time equivalent
employees. $__________
Section V: CERTIFICATION
(1) I hereby attest that all of the information provided on this application is true and accurate to the best of
my knowledge; (2) I understand that the information provided on this application applies only towards the
2011-2012 academic year and that in order to qualify for institutional aid in the future, I must apply each
year that I am enrolled as a student.
__________________________________________________
Student’s Signature
____________
Date
I hereby attest that all of the information provided on this application is true and accurate to the best of
my knowledge.
__________________________________________________
Non-Custodial Parent’s Signature
____________
Date
__________________________________________________
Non-Custodial Parent’s Spouse’s Signature
____________
Date
This worksheet is not valid unless signed and dated by the student, the non-custodial parent, the non-custodial
parent’s spouse.
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