1/28/2016
Your application was selected for review in a process called “Verification.” When a student file is selected for verification,
the Financial Aid Office must document and validate certain data elements from the FAFSA. The law says we must ask
you for additional information before awarding Federal Aid and Maryland Grants or Scholarships. If there are differences
between your application information and your financial documents, the Financial Aid Office may need to make
corrections electronically, and you may receive a corrected Student Aid Report (SAR).
Instructions: Complete all pages of this untaxed income form and submit it to HCC Student Financial
Aid Office as soon as possible. Please fill out this form in your browser and then print and sign. We
require ink signatures on this form. Required fields are outlined in red. Please contact us if you need
any additional information to fill out this form.
Student Information
________________________________________________________ _______________________________
Last Name First Name MI HCC ID Number
Step 1: Financial Information
Please answer all questions below.
In 2014 or 2015, did anyone in the household receive Supplemental Security Income (SSI)?
Student/Spouse
Parent
None
In 2014 or 2015, did anyone in the household receive Free or Reduced Price Lunch?
Student/Spouse
Parent
None
In 2014 or 2015, did anyone in the household receive TANF (Cash Assistance)?
Student/Spouse
Parent
None
In 2014 or 2015 did anyone in the household receive WIC (Women and Children Nutrition
Program)?
Student/Spouse
Parent
None
In 2015 did anyone in the household RECEIVE child support?
If yes, enter annual amount received in 2015: $________________
Student/Spouse
Parent
None
Student Financial Aid Office
11400 Robinwood Drive
Hagerstown, MD 21742
finaid@hagerstowncc.edu
FAX: 301-791-9165
2016-2017
Untaxed Income Form
WARNING: If you purposely give false or misleading information on this worksheet, you may be fined, be sentenced to jail, or both.
1/28/2016
Step 2: Untaxed Income information
If the section does not apply to you please enter N/A in the first line.
A. Payments to tax-deferred pension and retirement savings
List any payments (direct or withheld from earnings) to tax-deferred pension and retirement
savings plans (e.g., 401(k) or 403(b) plans), including, but not limited to, amounts reported on W-2
forms in Boxes 12a through 12d with codes D, E, F, G, H, and S. Submit a copy of all W2’s
received for 2015 to the Financial Aid Office.
Name of Person Who Made the Payment
Total Amount Paid in 2015
$
$
$
B. Housing, food, and other living allowances paid to members of the military, clergy, and
others
Include cash payments and/or the cash value of benefits received.
Do not include the value of on-base military housing or the value of a basic military allowance for
housing.
Name of Recipient
Amount of Benefit
Received in 2015
$
$
$
C. Veterans non-education benefits
List the total amount of veterans non-education benefits received in 2015. Include Disability,
Death Pension, Dependency and Indemnity Compensation (DIC), and/or VA Educational Work-
Study allowances.
Do not include federal veterans’ educational benefits such as: Montgomery GI Bill, Dependents
Education Assistance Program, VEAP Benefits or Post-9/11 GI Bill.
Name of Recipient
Type of Veterans
Non-education Benefit
Amount of Benefit
Received in 2015
$
$
$
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D. Other untaxed income
List the amount of other untaxed income not reported and not excluded elsewhere on this form.
Include untaxed income such as workers’ compensation, disability, Black Lung Benefits, untaxed
portions of health savings accounts from IRS Form 1040 Line 25, Railroad Retirement Benefits,
etc.
Do not include any items reported or excluded in A – C above. In addition, do not include
student aid, Earned Income Credit, Additional Child Tax Credit, Temporary Assistance to Needy
Families (TANF), untaxed Social Security benefits, Supplemental Security Income (SSI),
Workforce Investment Act (WIA) educational benefits, combat pay, benefits from flexible spending
arrangements (e.g., cafeteria plans), foreign income exclusion, or credit for federal tax on special
fuels.
Name of Recipient
Type of Other
Untaxed Income
Amount of Other
Untaxed Income
Received in 2015
$
$
$
F. Money received or paid on the student’s behalf
List any money received or paid on the student’s behalf (e.g., payment of student’s bills) and not
reported elsewhere on this form. Enter the total amount of cash support the student received in
2015. Include support from a parent whose information was not reported on the student’s 2016–
2017 FAFSA, but do not include support from a parent whose information was reported. For
example, if someone is paying rent, utility bills, etc., for the student or gives cash, gift cards, etc.,
include the amount of that person's contributions unless the person is the student’s parent
whose information is reported on the student’s 2016–2017 FAFSA. Amounts paid on the
student’s behalf also include any distributions to the student from a 529 plan owned by someone
other than the student or the student’s parents, such as grandparents, aunts, and uncles of the
student.
Purpose: e.g., Cash, Rent,
Books
Amount Received in
2015
$
$
$
$
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Additional information:
So that we can fully understand the student’s family's financial situation, please provide below
information about any other resources, benefits, and other amounts received by the student and
any members of the student’s household. This may include items that were not required to be
reported on the FAFSA or other forms submitted to the financial aid office, and include such things
as federal veterans’ education benefits, military housing, SNAP, TANF, etc.
If more space is needed, provide a separate page with the student’s name and ID number at the
top.
Name of Recipient
Type of
Financial Support
Amount of Financial
Support Received in
2015
$
$
$
$
$
Comments pertaining to supporting the household size listed:
By signing this form you are certifying that all the information reported on it is complete and correct.
________________________________
________________________________________________
Student Signature Date
________________________________________________________________________________
Parent Signature (Required for Dependent Students) Date