FILER'S name, street address, city, state, zip code, and telephone number.field contains State University Metropolis, OH 72727
FILER'S federal identification no.field contains 98-1234567
STUDENT'S social security numberfield contains 000-00-4321
STUDENT'S namefield contains Jim Grant
Street address (including apt. no.)field contains 1010 Anywhere St.
City, state, and ZIP codefield contains Hometown, OH 77777
1. Payments received for qualified tuition and related expensesfield contains $5000
8 Checked if at least half-time studentfield contains x