DECLARATION OF SEPARATION/DIVORCE
I, __, do hereby swear/affirm that I no longer consider myself to be the
(Print Student Name)
wife/husband of .
(Print Former Spouse Name)
I currently reside at
__.
Address City State Zip
My former spouse currently resides at
__.
Address City State Zip
We have not co-habited since ____/__ and we have no plans to do so in the future.
Month / year
Applicant/Parent Signature Date
Check only one (1) option below:
I am separated and have attached all copies of W-2’s from both the student and spouse. I give
permission to the Financial Aid Office to separate income and correct my FAFSA, if required. I
have completed the income Separated/Divorced Income Verification pages included with this form.
I am separated and have already separated/made corrections to the household income on the
FAFSA.
I am divorced and have attached all copies of W-2’s from both the student and former spouse. I give
permission to the Financial Aid Office to separate income and correct my FAFSA, if required. I
have completed the income Separated/Divorced Income Verification pages included with this form.
I am divorced and have already separated/made corrections to the household income on the FAFSA.
Please attach a copy of your divorce, separation, or interlocutory agreement. Failure to do so may
delay further processing of your aid application.
Declaration of Separation/Divorce Page 1 of 4
Student Financial Aid
South Louisiana Community College
Know. Know How.
SEPARATED/DIVORCED INCOME VERIFICATION
Print Student Name:____ LoLa ID:__
Address:____
E-mail:___ Phone:____
Your application for federal financial aid indicates that you are divorced or separated as of the date your
FAFSA was filed but filed a joint tax return. Federal regulations require that we have a signed statement
from you indicating how the reported income was divided between you and your spouse.
Based on your tax return and other documents, please divide your income (between you and your
spouse) as shown below, and sign on the reverse side. If you have any questions regarding this form,
please contact this office.
Total on Tax Return Student Spouse
Income
Wages, salaries, tips, etc.: $____ $____ $____
Tax-exempt Interest: $____ $____ $____
Dividends: $____ $____ $____
Refund of state/local taxes: $____ $____ $____
Alimony received: $____ $____ $____
Business income or loss: $____ $____ $____
Capital gain or loss: $____ $____ $____
Other gains or losses: $____ $____ $____
IRA distribution: $____ $____ $____
Pensions and Annuities: $____ $____ $____
Rents, Royalties, partnerships,
estates, trusts, etc.: $____ $____ $____
Farm income or loss: $____ $____ $____
Unemployment compensation: $____ $____ $____
Social security benefits: $____ $____ $____
Other income: $____ $____ $____
TOTAL INCOME: $____ $____ $____
(Must match total on tax returns)
Declaration of Separation/Divorce Page 2 of 4
____
Student Financial Aid
South Louisiana Community College
Know. Know How.
Total on Tax Return Student Spouse
Adjustments to Income
Educator expenses: $$$____
Certain Business Expenses: $$$____
(Line 24 on 1040)
Health savings account deduct: $$$____
Moving expenses: $$$____
Self-employment tax: $$$____
Self-employed SEP, SIMPLE, etc: $$$____
Self-employ health insurance: $$$____
Penalty on early w/d of savings: $$$____
Alimony paid: $$$____
IRA Deduction: $$$____
Student loan interest deduct: $$$____
Tuition and Fees Deduction: $$$____
Other Adjustments to income: $$$____
TOTAL ADJUSTMENTS: $$$____
ADJUSTED GROSS INCOME: $$$____
Total income -total adjustments=AGI (Must match with AGI on tax returns)
TAX PAID: $$$____
Must be the same percentage as each person’s adjusted gross income
Education Credits: $$$____
I certify that the above information is correct:
Signature of Applicant Date
Submit this form to the Financial Aid Office by
Fax: (337) 521-8992
In-person at your local campus (if other than Lafayette, have the campus fax to 337-521-8992)
Declaration of Separation/Divorce Page 3 of 4
____
____
_ ___
____
South Louisiana Community College
Know. Know How.
CERTIFICATIONS AND SIGNATURES
The person signing below certifies that all of the
information reported is complete and correct.
Student Financial Aid
WARNING: If you purposely give false or
misleading information, you may be fined, be
sentenced to jail, or both.
Print Student’s Name
Student’s Signature
Student’s LoLa ID Student Date of Birth
D
Discord