Fill - Free fillable 2015-16ParentIncomeCertification 2006-2007 Verification Worksheet PDF form

California Lutheran University – Office of Financial Aid

2015-16 Parent Income Certification

RETURN TO:

CLU Office of Financial Aid

60 West Olsen Road #1375

Thousand Oaks, CA 91360

EMAIL: finaid@callutheran.edu

FAX: (805) 493-3114

Complete items B – H of this worksheet with responses from the parent whose information is on

the FAFSA.

 If any item does not apply, enter “N/A” or “0”

 If more space is needed, attach a separate page with the student’s name and ID number at the

top and include the additional information.

A. Student Information

Last Name

First Name

M.I.

CLU ID # or Social Security Number

@callutheran.edu

Date of Birth

E-mail address

Current phone number (include area code)

Address (include Apt #)

City

State

Zip

B. Payment 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.

Name of person who made the payment(s)

Total amount paid between

January 1 - December 31, 2014

C. Child Support Received

List the actual amount of any child support received in 2014 for the children in your household.

Do not include foster care payments, adoption payments, or any amount that was court-ordered but not actually paid.

Name of person who received child support payment(s)

Name of child for whom child support was paid

Total amount received between

January 1 - December 31, 2014

D. 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

Type of benefit received

Total amount received between

January 1 - December 31, 2014

E. Veterans non-education benefits

List the total amount of veterans non-education benefits received in 2014. 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, Post-

9/11 GI Bill

Name of recipient

Type of Veterans non-education benefit

received

Total amount received between

January 1 - December 31, 2014

F. 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 B – E 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

Total amount received between

January 1 - December 31, 2014

G. Money received or paid on the parent’s behalf

List any money received or paid on the parent’s behalf (e.g., payment of parents’ bills) and not reported elsewhere on this form. If someone is

paying rent, utility bills, etc., for the parent or gives cash, gift cards, etc., include the amount of that person's contributions .

Purpose (e.g. Cash, Rent, Cell Phone, Auto Insurance…)

Source

Total amount received between

January 1 - December 31, 2014

H. Additional information

So that we can fully understand the family's financial situation, please provide below information about any other resources, benefits, and other

amounts received by the parent. 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.

Name of recipient

Type of financial support

Total amount received between

January 1 - December 31, 2014

I. Certifications and Signatures

Each person signing below certifies that all of the information reported is complete and correct. The student and one parent whose information is

reported on the FAFSA must sign and date. WARNING: If you purposely give false or misleading information you may be fined, be sentenced to

jail, or both.

Student’s Signature - Required

Date

Parent’s Signature - Required

Date

PLEASE RETURN TO CALIFORNIA LUTHERAN UNIVERSITY AT THE ADDRESS LISTED ABOVE.

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