2010-2011 Verification of Separation of Income

This form should be used for an applicant or applicant’s parent (in the case of a dependent student) who filed a
joint return for the year 2009 but is now widowed, divorced, or separated. You must use the joint return to
factor out the individual income and taxes paid.
Read the instructions below BEFORE completing this form. Attach a copy of your signed joint Federal tax return if you
have not yet submitted one to the University of Phoenix. To assist you with completing the Separation of Income Form,
we are providing you with the specific line references for the 2009 US Tax Returns.

Instructions
Starting with the income figures from your W-2(s), add in any income from the joint return which represents your
personal income. Any other income or interest earned should be assessed at 50%, to include business or farm gains or
losses. Also, if the AGI listed on your joint return was adjusted (“Adjustments to Income”), you should reduce the AGI
by the portion of the adjustment that applies solely to you. For example, if an adjustment was made for moving
expenses, which applies to you and your spouse, only 50% of the adjusted amount can be applied against your income.
If you do not assess these items at 50%, you must provide the appropriate tax documents to support your assessment
amounts.

Once you have determined your AGI, establish what percentage of the joint AGI was credited to you, and assess the
joint tax paid by that same percentage.

Example: Your AGI was $35,000. The AGI on the joint tax return was $58,000. The tax paid on the joint return was
$3,000. Divide the $35,000 by $58,000. This gives you a figure of .6034 or 60.3%. Multiply the $3,000 by 60.3%.
Your portion of tax paid equals $1,809.
Your AGI/joint AGI = % of income
Total joint tax X % of income = Your tax

IRS IRS IRS

ITEM $ Amount 1040 1040A 1040EZ
2009 earnings from W-2 form(s) N/A N/A N/A
Taxable interest Line 8a Line 8a Line 2
Ordinary dividends Line 9A Line 9a N/A
Taxable refunds, credits, or offsets of state and local income taxes Line 10 N/A N/A
Alimony received Line 11 N/A N/A
Business income (+) or loss (-) Line 12 N/A N/A
Capital gain (+) or loss (-) Line 13 Line 10 N/A
Other gains (+) or losses (-) Line 14 N/A N/A
Taxable IRA Distributions Line 15b Line 11b N/A
Taxable pensions and annuities Line 16b Line 12b N/A
Rents, royalties, trusts, ect Line 17 N/A N/A
Farm income (+) or loss (-) Line 18 N/A N/A
Unemployment compensation Line 19 Line 13 Line 3
Social Security Benefits Line 20b Line 14b N/A
Other taxable income Line 21 N/A N/A
(1) TOTAL INCOME

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 2010-2011 Verification of Separation of Income

IRS IRS IRS

ITEM $ Amount 1040 1040A 1040EZ
Educator Expenses Line 23 Line 16 N/A
Certain business expenses of reservists, performing artists, and fee-
basis government officials Line 24 N/A N/A
Health Savings Account Deduction Line 25 N/A N/A
Moving Expenses Line 26 N/A N/A
One-half of self employment tax Line 27 N/A N/A
Self-employed SEP, SIMPLE and qualified plans Line 28 N/A N/A
Self-employed health insurance deduction Line 29 N/A N/A
Penalty on early withdrawal of savings Line 30 N/A N/A
Alimony paid Line 31a N/A N/A
IRA Deduction Line 32 Line 17 N/A
Student Loan Interest Deduction Line 33 Line 18 N/A
Tuition and Fees Deduction Line 34 Line 19 N/A
Domestic Production Activities Deduction Line 35 N/A N/A
(2) Total Adjustments to Income
(1) - (2) = Total 2009 Adjusted Gross Income

Each item above should be assessed at 50% or higher. If you do not assess these items at 50% or higher (as an income
or adjustment item that did not apply to you in part or in total), you must provide the appropriate tax documents to
support your assessment amounts.

I affirm that the above figures accurately reflect my 2009 Adjusted Gross Income (AGI). I have attached copies of my
W-2 form(s) (or signed statement) and our signed joint tax return used in reporting my 2009 earnings on this form. I
understand that if I do not correctly separate my income and adjustments to income items, or do not provide supporting
documents, it may cause delays in processing the financial aid file. I also affirm and authorize the University of Phoenix
to make any necessary corrections to the income figures in accordance with Federal regulations.

__________________________________ _______________________ __________________________________

Student Name (Print) Date IRN

_______________________________________________ _________________________________________
Student’s Signature (Independent Students Only) Last 4 digits of SSN

_______________________________________________ __________________________________________
Parent Name (Print) (Dependent Student Only) Parent Signature (Dependent Student Only)

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