Eligibility and Earnings Certification - McNair Scholars Program University of Wisconsin Oshkosh

Student Name

First Middle Last

A student is Independent if ANY of the following conditions are true:

You were 24 years of age on or before December 31st of last year;
You have a dependent child or parent;
You are a member or veteran of the US Armed Forces; or
At any time since you turned 13, both of your parents were deceased, you were in foster care, or you were a dependent or ward of the court

You are a Dependent if ALL of the following conditions apply to you:

You were under the age of 24 on December 31st of last year;
You do not have a dependent child;
You are not a member or veteran of the U.S. Armed Forces; or
At any time since you turned 13, one or both of your parents were living, you were not in foster care, nor were you a dependent or ward of the court.

What is the student's federal tax filing status according to their most recently filed federal taxes?*

Independent
Dependent

If Dependent, the tax filer (parent or guardian) must certify and sign this form.

Certifying Individual's Name (parent or guardian)*

First Last

Household Size: How many people are in your household?*

If Independent, include yourself, your spouse, and any other dependents. If Dependent, include yourself, your parents or guardians, and all other dependents.

What was last year's Federal Taxable Income (for yourself if Independent, your parents or guardians if Dependent)?*

No taxes filed
Equal to or under $18,735
$18,736 to $25,365
$25,366 to $31,995
$38,626 to $45,255
$45,256 to $51,885
$51,886 to $58,515
$58,516 to $65,145
$65,145 or more

Line 6 of Form 1040EZ, Line 27 of Form 1040A; or Line 43 of Form 1040

I certify that the information above is true, correct and complete to the best of my knowledge.*

I agree