Fillable 2015-16StudentIncomeCertification 2006-2007 Verification Worksheet

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2015-16StudentIncomeCertification 2006-2007 Verification Worksheet

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California Lutheran University – Office of Financial Aid
2015-16 Student 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
Answer each question below as it applies to the student (and their spouse, if married) whose
information is on the FAFSA.
If any item does not apply, enter “N/A” for Not Applicable where a response is requested, or
enter 0 in an area where an amount is requested.
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
Date of Birth
Current phone number (include area code)
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 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. 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 2015–2016 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, etc.
Purpose
(e.g. Cash, Rent, Books, Cell Phone, Auto Insurance…)
Source
Total amount received between
January 1 - December 31, 2014
$
$
$
H. 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.
Name of recipient
Type of financial support
Total amount received between
January 1 - December 31, 2014
$
$
$
$
I. Certifications and Signatures
The student must sign and date below. If married, the spouse’s signature is optional. Each person signing below certifies that all of the information
reported is complete and correct. WARNING: If you purposely give false or misleading information you may be fined, be sentenced to jail, or
both.
Student’s Signature - Required
Date
Spouse’s Signature
Date
PLEASE RETURN TO CALIFORNIA LUTHERAN UNIVERSITY AT THE ADDRESS LISTED ABOVE.
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2015-16StudentIncomeCertification 2006-2007 Verification Worksheet

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Completed 11 February 2020

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