D. Parent’s Income Information to Be Verified
Untaxed Income
My parents received sources of untaxed income in 2013. (Sources may include payments to tax-deferred pension/retirement
savings, child support received, housing, food, and other living allowances paid to members of the military, clergy, and others,
veterans non-education benefits, workers’ compensation, state disability, Black Lung benefits, untaxed portions of health
savings accounts, railroad retirement benefits, social security benefits, TANF, CalWORKs, unemployment benefits, general
relief, alimony, money received or paid on the your behalf or any other untaxed income received in 2013). I have indicated the
source and the amount below.
Sources of Untaxed Income - Parent(s) 2013
mount
Parent(s) filed a tax return
My parent(s) used the IRS Data Retrieval Tool in FAFSA on the Web to retrieve and successfully transfer their 2013 IRS income
information into the FAFSA. Skip to Section E.
2013 Parent(s) IRS tax return transcript is attached. Skip to Section E.
Parent(s) did not file a tax return
My parent(s) was/were not employed and had no income earned from work in 2013.
My parent(s) was/were employed in 2013 and were not required to file a tax return. Listed below are the names of the employer
and the amount earned. W-2 forms are attached.
Employer’s Name - Parent(s) 2013
mount Earned IRS W-2 Attached?
E. Additional Information – Other Support Received
________________________________________________________________________________
________________________________________________________________________________
________________________________________________________________________________
F. Student and/or Parent’s Other Information to Be Verified
Check the box below if someone in the student’s parent’s household (listed in Section B) received benefits from the
Supplemental Nutrition Assistance Program (SNAP-food stamps) any time during the 2012 or 2013 calendar years.
One of the persons listed in Section B of this worksheet received SNAP benefits in 2012 or 2013.
Check the box below and complete the section below if you or one or both of your parents paid child support in 2013.
Myself or One (or both) of my parents listed in Section B of this worksheet paid child support in 2013. I have indicated below the
name of the person who paid the child support, the name of the person to whom the child support was paid, the names of the
children for whom child support was paid, and the total annual amount of child support that was paid in 2013 for each child. If
asked by the school, I will provide documentation of the payment of child support. If you need more space, attach a separate page
that includes the student’s name and Student Number at the top.
Name of Person Who Paid
Child Support
Name of Person to Whom
Child Support was Paid
Name of Child for Whom
Support Was Paid
Amount of Child
Support Paid in 2013
G. Certification and Signatures
Each person signing this worksheet certifies that all of the information reported is complete and correct. The
student and one parent must sign and date.
_________________________________________________ _________________________________
Student’s Signature Date
_________________________________________________ _________________________________
Parent’s Signature Date
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
