Download Asset Worksheet - Indiana University South Bend

Asset Worksheet
2016 – 2017 Academic Year
Office of Financial Aid and Scholarships ▪ Indiana University South Bend ▪ P.O. Box 7111 ▪ South Bend, IN 46634-7111
Phone: (574)520-4357 Fax: (574) 520-5561 Email: [email protected] Website: financialaid.iusb.edu
Print Student Name
University ID Number
We are required to collect asset information if a student and/or parent was ineligible to file their taxes using either a 1040A
or EZ form. Amounts listed below should reflect assets held as of the date you completed the FAFSA. If you have any
questions about this form, contact the IU South Bend Office of Financial Aid and Scholarships at (574) 520-4357.
Please complete the sections as checked here:
____Dependent Student - complete the entire form.
____Independent Student - complete the student/spouse section and certification only.
Definitions:
Net Worth: The value minus the debt. If net worth is zero (0) or any debt is larger than the respective value, provide a
detailed explanation of the debt on the back of this form.
Farm Value and Farm Debt: Refers only to an investment farm. Do not include the value of a farm on which you live and
materially participate/operate.
SECTION I: STUDENT/SPOUSE
Each section must be completed, even if the answer is N/A or $0.
Cash, savings, and checking accounts total $
Investments Value:
Value $
- Debt $
= Net Worth $
Include real estate (exclude your home), trust funds, money market funds, mutual funds, certificates of deposit, stocks, stock options,
bonds, other securities (exclude if part of your retirement plan), education IRAs, installment and land sale contracts (including
mortgages held), commodities, UGMA and UTMA accounts (if you are the owner), etc. Also include qualified education benefits or
educational savings accounts, 529 plans (for dependent students these are reported as parental assets).
Business/Farm:
Is this a family owned/controlled business (more than 50% of the business is owned by persons who are directly related or
are or were related by marriage)?
Yes _____ No _____ N/A____
Does the business employ 100 or fewer full time/full time equivalent employees?
Yes _____ No _____ N/A____
In whose name is the business?
_______________________________________________________________________________
(If more than one business is owned, please attach a separate sheet listing all business names, owners and net value/debt.)
Value* $
- Debt $
= Net Worth $
*Include the market value of land, buildings, machinery, equipment, inventory, etc. Business and/or investment farm debt means only
those debts for which the business or farm was used as collateral.
If the investment, business, or farm has been sold, please indicate date this occurred:
PARENT SECTION AND CERTIFICATION ON REVERSE
SECTION II: PARENT(S)Each line must be completed, even if the answer is N/A or $0.
REQUIRED INFORMATION
Parent’s marital status: (circle one)
Single
Married
Separated
Divorced
Widowed Unmarried/living together
Marital status date _________________________
Your parent(s) state of legal residence:
Date legal residence established:
Parent 1 Full Name:
_______________________________________
Parent 1 Date of Birth:
Parent 1 Social Security Number:
Parent 2 Full Name:
_______________________________________
Parent 2 Date of Birth:
Parent 2 Social Security Number:
Cash, savings, and checking accounts total $
Investments Value:
Value* $
- Debt $
= Net Worth $
Include real estate (exclude your home), trust funds, money market funds, mutual funds, certificates of deposit, stocks, stock options,
bonds, other securities (exclude if part of your retirement plan), education IRAs, installment and land sale contracts (including
mortgages held), commodities, UGMA and UTMA accounts (if you are the owner), etc. Also include qualified education benefits or
educational savings accounts, 529 plans (for dependent students these are reported as parental assets).
Business/Farm:
Is this a family owned/controlled business (more than 50% of the business is owned by persons who are directly related or
are or were related by marriage)?
Yes _____ No _____ N/A____
Does the business employ 100 or fewer full time/full time equivalent employees?
Yes _____ No _____ N/A ____
In whose name is the business?
_______________________________________________________________________________
(If more than one business is owned, please attach a separate sheet listing all business names, owners and net profit/loss.)
Value* $
- Debt $
= Net Worth $
*Include the market value of land, buildings, machinery, equipment, inventory, etc. Business and/or investment farm debt means only
those debts for which the business or farm was used as collateral.
If the investment, business, or farm has been sold, please indicate the date this occurred:
For both student and parent sections, explain the circumstances regarding any debts that are higher than values, or if net
worth is less than zero.
Section III: Certification
Everyone who provides information on this worksheet must sign below to certify that the information they have provided is
accurate as of the date signed. Anyone purposely giving false or misleading information on this form may be fined,
sentenced to jail, or both. Only one parent/stepparent signature is required for this form.
Student Signature
Date
H:\FAO\forms\16 - 17 Forms\Asset Worksheet 16 - 17.docx
Spouse or
Parent 1 or Parent 2 Signature
Date