NEW YORK STATE HIGHER EDUCATION SERVICES CORPORATION ...

NEW YORK STATE HIGHER EDUCATION SERVICES CORPORATION

EXCELSIOR SCHOLARSHIP INCOME QUESTIONNAIRE FOR RETURNING

Records from the NYS Department of Taxation and Finance indicate that a New York State income tax return for the 2018 tax year was not filed for either you, your parent(s) or your spouse.

To continue processing your Excelsior Scholarship application, please complete and sign this income verification questionnaire and upload it to . Your responses will be used to determine if you meet the income eligibility requirements for the Excelsior Scholarship.

A financial aid determination cannot be made without this form which must be received by HESC, by September 14, 2020, or your application will be withdrawn.

I. STUDENT INFORMATION 1. Student Name (Last, First, MI): __________________________________________________

2. Student SSN: _________ - _________ - _______________

3. Student Date of Birth: _________________________

4. Student Current Address: ________________________________________________________

II. STUDENT 2018 INCOME INFORMATION 1. For calendar year 2018, which of these describes you? I filed my own NYS income tax return I filed my own income tax return in another state / Name of State: _________ My income was included in my parent(s)' 2018 NYS tax return filings My income was included in my parent(s)' 2018 tax return filings in another state /Name of State: _________ My income was included in my spouse's 2018 NYS tax return filings Spouse Name_________________________________ Spouse SSN_____ - _____ - _____ My income was included in my spouse's 2018 tax return filings in another state/Name of State: _________ Spouse Name_________________________________ Spouse SSN_____ - _____ - _____ I was not required to file a tax return to 2018

2. PARENT 2018 INCOME INFORMATION Please provide the name and social security number of the parent(s)/stepparent(s) listed on your family's 2018 NYS income tax return or the parent with whom you live with or who provides the most support. ? If your parents are married or remarried, provide both parents information. ? If your parents are divorced/separated: Provide information for parent 1 and check N/A for parent 2. ? If you have established your own permanent household and are an independent student: For both parent 1 and 2, check N/A. 1. For calendar year 2018, which of these describes your parent's status? Married/remarried and filed a joint NYS income tax return Divorced/widowed and filed a NYS income tax return Single and filed a NYS income tax return Married/remarried filing separately Not required to file a tax return for 2018

HE9186 (Rev. 04/2020)

99 Washington Avenue, Albany, NY 12255 | hesc.

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You must enter the name and social security number of the tax filer exactly as it appears on the 2018 IT-201 that was filed.

2. Parent 1 Name (Last, First, MI):______________________________________ Parent 1 SSN: _________ - _________ - __________ Not applicable:

Parent 2 Name (Last, First, MI):______________________________________ Parent 2 SSN: _________ - _________ - ___________ Not applicable:

APPLICANT AFFIRMATION

By my signature below, I am affirming under the penalty of perjury that all the information I provided in this Income Questionnaire is true and complete.

_____________________________________ Signature of Scholarship Applicant

________________ Date

99 Washington Avenue, Albany, NY 12255 | hesc.

HE9186 (Rev. 04/2020)

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